MEDICARE: ROBERT ELVON 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	390200000X	Student in an Organized Health Care Education/Training Program	4301087650	MI
2	208800000X	Urology Physician	4301087650	MI
3	208800000X	Urology Physician	M-11868	ID

General Provider Information

NPI Number	:	1184740045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT ELVON JACKSON MD

Provider Business Mailing Address
First Line	:	875 S VANGUARD WAY
Second Line	:	SUITE 200 D
City	:	MERIDIAN
State	:	ID
Zip	:	83642
Country	:	US
Telephone Number	:	208-782-6730
Fax Number	:	208-759-7822

Provider Business Practice Location Address
First Line	:	875 S VANGUARD WAY
Second Line	:	SUITE 200 D
City	:	MERIDIAN
State	:	ID
Zip	:	83642
Country	:	US
Telephone Number	:	208-782-6730
Fax Number	:	208-759-7822

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	06/02/2026

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