Provider Demographics
NPI:1053917294
Name:JACKSON, WILLIAM IVAN III
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:IVAN
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7105 HORIZON WOOD LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80927-4117
Mailing Address - Country:US
Mailing Address - Phone:719-367-0753
Mailing Address - Fax:
Practice Address - Street 1:7105 HORIZON WOOD LN
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80927-4117
Practice Address - Country:US
Practice Address - Phone:719-367-0753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program