Active NPI
Courtney Matthew Jackson, D.D.S.
- Pediatric Dentistry
- Rexburg, ID
National Provider Identifier
1972864825
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Dentistry
- License
- D-4655-PD
- Practice address
- 859 S Yellowstone Hwy Ste 1202
Rexburg, ID 83440-6201 - Phone
- (208) 552-5439
- Fax
- (208) 552-5440
- NPI assigned
- Jun 6, 2012
- Last updated
- Feb 3, 2016
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Dentistry | 1223P0221X | 1433 | WY | |
| Pediatric Dentistry | 1223P0221X | D-4655-PD | ID | Primary |
Addresses
Primary practice location
859 S Yellowstone Hwy Ste 1202
Rexburg, ID 83440-6201
Mailing address
859 S Yellowstone Hwy Ste 1202
Rexburg, ID 83440-6201
Phone (208) 552-5439
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-4655-PD | ID | MD | Pediatric Dentist |
| 1433 | WY | MD | Pediatric Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Night Boat PLLC | Pediatric Dentistry | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1338940800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1454457600000",
"number": "1972864825",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "859 S YELLOWSTONE HWY STE 1202",
"city": "REXBURG",
"state": "ID",
"postal_code": "834406201",
"telephone_number": "208-552-5439",
"fax_number": "208-552-5440"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "859 S YELLOWSTONE HWY STE 1202",
"city": "REXBURG",
"state": "ID",
"postal_code": "834406201",
"telephone_number": "208-552-5439",
"fax_number": "208-552-5440"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "COURTNEY",
"middle_name": "MATTHEW",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2012-06-06",
"last_updated": "2016-02-03",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "WY",
"license": "1433",
"primary": false
},
{
"code": "1223P0221X",
"taxonomy_group": "",
"desc": "Dentist, Pediatric Dentistry",
"state": "ID",
"license": "D-4655-PD",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Rexburg, ID
- Karen O Ili
- Integrated Counseling and Wellness, Inc. (Integrated Counseling and Wellness)
- Intouch Recovery
- J & S Enterprises Inc (Medicine Shoppe #517)
- J. B. Egbert Chiropractic LLC
- Alicia Jacobson, LMSW
- James C Thomason DMD, PA (North Fork Dental)
- James Cannon Allen DDS PC (Rockhouse Dentistry)
- James Rex Cutler DPM PLLC (Mountain River Foot and Ankle Care)
- Taylor J Jardine, D.D.S.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.