Basic Information
| Provider Information | |||||||||
| NPI: | 1427020957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKMON | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86370 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571186370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053227510 | ||||||||
| FaxNumber: | 6053226475 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 69TH ST | ||||||||
| Address2: | STE 1500 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571088170 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053225700 | ||||||||
| FaxNumber: | 6053225704 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 477 | SD | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 12200 | 05 | ND | MEDICAID | 46022474352 | 05 | NE | MEDICAID | 854000 | 01 | SD | ARAZ/ AMERICA'S PPO | OTHER | 944611700 | 05 | MN | MEDICAID | 0040537 | 01 | SD | BLUE CROSS | OTHER | 140M8JA | 01 | MN | CC SYSTEMS/ BLUE PLUS | OTHER | 142415 | 01 | MN | UCARE | OTHER | 412991020844 | 01 | SD | PREFERRED ONE | OTHER | 6552790 | 05 | SD | MEDICAID | 6570753 | 05 | SD | MEDICAID | 800013808 | 01 | SD | RR MEDICARE | OTHER | HP37115 | 01 | SD | HEALTHPARTNERS | OTHER | 15096 | 01 | SD | MIDLANDS CHOICE | OTHER | 20814 | 01 | SD | SANFORD HEALTH PLAN | OTHER | 3989442 | 05 | IA | MEDICAID | 57108C003 | 01 | SD | WPS TRICARE | OTHER | 9205351 | 01 | SD | DAKOTACARE | OTHER | 040121002 | 01 | MN | PRIMEWEST | OTHER |