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1437174638

NPI Code Detail

MEDICARE: PHILIP JACKSON M.D.

MEDICARE: PHILIP 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
1	208000000X	Pediatrics Physician	4301025901	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1020381	OTHER	MI	MCLAREN HEALTH PLAN HAN
2	17572	OTHER	MI	MCARE MMMI
3	350D410030	OTHER	MI	BCN BLUE CHOICE FENTON
4	700H228520	OTHER	MI	BCBSM
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	1437174638	OTHER	MI	NPI
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	0994622	OTHER	MI	HEALTH PLUS MMMI
9	350D410030	OTHER	MI	BCBS MMMI

General Provider Information

NPI Number	:	1437174638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP JACKSON M.D.

Provider Business Mailing Address
First Line	:	26650 EUREKA RD
Second Line	:	SUITE C-1
City	:	TAYLOR
State	:	MI
Zip	:	48180-4835
Country	:	US
Telephone Number	:	734-941-4991
Fax Number	:	734-941-4919

Provider Business Practice Location Address
First Line	:	2500 HAMLIN DR
Second Line	:
City	:	INKSTER
State	:	MI
Zip	:	48141-2348
Country	:	US
Telephone Number	:	313-561-5100
Fax Number	:	313-565-0309

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	10/21/2009

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Practice Location Address:

2500 HAMLIN DR
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48141-2348

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1023268661 — MRS. JUNG M NICHOLS LMSW
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INKSTER, MI
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1528290301 — ANITA H MENDOZA LCSW
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INKSTER, MI
48141-2348

Practice Phone: 313-561-5100
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1346542065 — MRS. LAURA MATTSON ZANG N.P.
Practice Location Address:

2500 HAMLIN DR
INKSTER, MI
48141-2348

Practice Phone: 313-561-5100
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1588939136 — ANN M SCHNEIDER RDH
Practice Location Address:

2500 HAMLIN DR
INKSTER, MI
48141-2348

Practice Phone: 313-561-5100
Practice Fax: 313-565-0309

1932443330 — KRYSTEN LEIGH LYNCH NP
Practice Location Address:

2500 HAMLIN DR
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48141-2348

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Directions to “ PHILIP JACKSON M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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