1073585238 NPI number — MARK A JACKSON MD

Table of content: MARK A JACKSON MD (NPI 1073585238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073585238 NPI number — MARK A JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MARK
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073585238
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10850 E TRAVERSE HWY
Provider Second Line Business Mailing Address:
STE 4400
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49684-1364
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-346-6930
Provider Business Mailing Address Fax Number:
231-346-6017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 PAVILIONS CIRCLE
Provider Second Line Business Practice Location Address:
MARK A JACKSON MD PLC
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-935-0913
Provider Business Practice Location Address Fax Number:
231-935-0984
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  051555 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X , with the licence number: 4301051555 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1820487 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080B86010 . This is a "BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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