Basic Information
| Provider Information | |||||||||
| NPI: | 1669733580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKMAN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 269 S CANDY LN | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286396172 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2012 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 58317 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0005X | 58317 | AZ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Undersea and Hyperbaric Medicine | 207Q00000X | 58317 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.