1336381631 NPI number — GARRETT J JACKSON M.D.

Table of content: GARRETT J JACKSON M.D. (NPI 1336381631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336381631 NPI number — GARRETT J JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
GARRETT
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1336381631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 W WHITE RIVER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47303-4988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-668-5621
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 LANDMARK DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-6652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-448-7981
Provider Business Practice Location Address Fax Number:
765-447-4172
Provider Enumeration Date:
04/01/2009

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: 390200000X , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: 01074880A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com