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General NPI Number Information
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NPI Number | 1740439025
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Entity Type | Organization
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Legal Business Name | MARK A JACKSON MD PLC
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Dates
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Enumeration Date | 09/11/2008
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Last Update Date | 12/18/2008
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Provider Practice Location Address
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Address Line | 1000 PAVILLIONS CIR
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City | TRAVERSE CITY
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State | MI
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Zip | 49684-3198
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Country | US
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Telephone | 231-935-0913
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Fax | 231-935-0984
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Provider Business Mailing Address
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Address Line | PO BOX 1267
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City | TRAVERSE CITY
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State | MI
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Zip | 49685-1267
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Country | US
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Telephone | 231-935-0913
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Fax | 231-935-0984
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. MARK A JACKSON
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Credential | MD
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Telephone | 231-935-0913
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 4301051555
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License Number State | MI
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