Healthcare Provider Details

I. General information

NPI: 1184602666
Provider Name (Legal Business Name): ORLAN JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 HIGHWAY 49 N
BEULAH ND
58523-6038
US

IV. Provider business mailing address

1312 HIGHWAY 49 N
BEULAH ND
58523-6038
US

V. Phone/Fax

Practice location:
  • Phone: 701-873-4445
  • Fax: 701-873-4199
Mailing address:
  • Phone: 701-873-4445
  • Fax: 701-873-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberND5650
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: