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NPI Code Detail

MEDICARE: GARRETT J JACKSON M.D.

MEDICARE: GARRETT J JACKSON M.D.
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
1390200000XStudent in an Organized Health Care Education/Training ProgramWV
2207T00000XNeurological Surgery Physician01074880AIN

General Provider Information

NPI Number : 1336381631
Entity Type Code : Individual
Provider Name (Legal Business Name) : GARRETT J JACKSON M.D.
Provider Business Mailing Address
First Line : 11109 PARKVIEW PLAZA DR # 117
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1701
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 11104 PARKVIEW CIRCLE DR STE 110
Second Line :
City : FORT WAYNE
State : IN
Zip : 46845-1673
Country : US
Telephone Number : 260-425-6780
Fax Number : 260-425-6615
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/01/2009
Last Update Date : 12/11/2025

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Directions to “ GARRETT J JACKSON M.D.” Practice Location

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