Healthcare Provider Details

I. General information

NPI: 1801730593
Provider Name (Legal Business Name): MARTY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2026
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 BELLILE ST UNIT 294
SAINT MICHAEL ND
58370-7006
US

IV. Provider business mailing address

PO BOX 108
SAINT MICHAEL ND
58370-0108
US

V. Phone/Fax

Practice location:
  • Phone: 701-381-6194
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: