MEDICARE: DR. MARK R JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	23559	SC
2	2086S0129X	Vascular Surgery Physician	23559	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033177530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK R JACKSON MD

Provider Business Mailing Address
First Line	:	3 SAINT FRANCIS DR
Second Line	:	SUITE 330
City	:	GREENVILLE
State	:	SC
Zip	:	29601-3971
Country	:	US
Telephone Number	:	864-255-1834
Fax Number	:	864-255-1836

Provider Business Practice Location Address
First Line	:	3 SAINT FRANCIS DR
Second Line	:	SUITE 330
City	:	GREENVILLE
State	:	SC
Zip	:	29601-3971
Country	:	US
Telephone Number	:	864-255-1834
Fax Number	:	864-255-1836

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	11/06/2020

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