1700862992 NPI number — THOMAS V JACKSON MD

Table of content: THOMAS V JACKSON MD (NPI 1700862992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700862992 NPI number — THOMAS V JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
THOMAS
Provider Middle Name:
V
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:
1700862992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 387
Provider Second Line Business Mailing Address:
DIVINE SAVIOR HEALTHCARE INC
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53901-0387
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-742-4131
Provider Business Mailing Address Fax Number:
608-745-5173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2817 NEW PINERY RD
Provider Second Line Business Practice Location Address:
DIVINE SAVIOR HEALTHCARE INC
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53901-9257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-742-4131
Provider Business Practice Location Address Fax Number:
608-745-5173
Provider Enumeration Date:
12/20/2005

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: 207P00000X , with the licence number:  21269020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30128500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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