Healthcare Provider Details

I. General information

NPI: 1184740045
Provider Name (Legal Business Name): ROBERT ELVON JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 S VANGUARD WAY SUITE 200 D
MERIDIAN ID
83642
US

IV. Provider business mailing address

875 S VANGUARD WAY SUITE 200 D
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-782-6730
  • Fax: 208-759-7822
Mailing address:
  • Phone: 208-782-6730
  • Fax: 208-759-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301087650
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301087650
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberM-11868
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: