Provider Demographics
NPI:1609923028
Name:JACKSON, ALFRED (MD)
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15001 E OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-4186
Mailing Address - Country:US
Mailing Address - Phone:303-693-1550
Mailing Address - Fax:303-693-8309
Practice Address - Street 1:15001 E OXFORD AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-4186
Practice Address - Country:US
Practice Address - Phone:303-693-1550
Practice Address - Fax:303-693-8309
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO213872084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01213875Medicaid