Healthcare Provider Details

I. General information

NPI: 1699632059
Provider Name (Legal Business Name): MARSHAWN BACON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W. FRANKLIN ST.
JACKSON MI
49203
US

IV. Provider business mailing address

2104 W MICHIGAN AVE APT 201
JACKSON MI
49202-4071
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-7573
  • Fax:
Mailing address:
  • Phone: 517-788-9147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: