Healthcare Provider Details

I. General information

NPI: 1922593359
Provider Name (Legal Business Name): MARK JACKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 PERRY HILL RD
MONTGOMERY AL
36109-3725
US

IV. Provider business mailing address

8730 RIDGESTONE CT
MONTGOMERY AL
36117-8875
US

V. Phone/Fax

Practice location:
  • Phone: 180-145-5538
  • Fax:
Mailing address:
  • Phone: 801-455-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001488
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: