Healthcare Provider Details

I. General information

NPI: 1427259191
Provider Name (Legal Business Name): TODD EDWARD JACKMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 FRANCE AVE S STE 408
EDINA MN
55435-4549
US

IV. Provider business mailing address

1950 NORTHWESTERN AVE S STE 102
STILLWATER MN
55082-7615
US

V. Phone/Fax

Practice location:
  • Phone: 651-430-3800
  • Fax: 651-430-3827
Mailing address:
  • Phone: 651-430-3800
  • Fax: 651-430-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number47215
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD00049377
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: