Individual
DR. ALFRED VAUGHN D JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
416 MAIN STREET, LA JARA, CO 81140-0272
(719) 274-4500
(719) 274-4504
Mailing address
PO BOX 272, 416 MAIN STREET, LA JARA, CO 81140-0272
(719) 274-4500
(719) 274-4504
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
1823241205
UT
207Q00000X
Family Medicine Physician
Primary
31351
CO
207Q00000X
Family Medicine Physician
89132
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01313519
—
CO
05
—
89132
—
NM
Enumeration date
05/15/2006
Last updated
11/13/2013
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