MEDICARE: DR. MICHAEL B. JACKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084F0202X	Forensic Psychiatry Physician	25MA08023100	NJ
2	2084P0800X	Psychiatry Physician	25MA08023100	NJ
3	2084P0800X	Psychiatry Physician	234087	NY

General Provider Information

NPI Number	:	1073600896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL B. JACKSON M.D.

Provider Business Mailing Address
First Line	:	112 CHURCHILL RD
Second Line	:
City	:	TENAFLY
State	:	NJ
Zip	:	07670-3120
Country	:	US
Telephone Number	:	201-588-9475
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 RIVER ST
Second Line	:	3D
City	:	HOBOKEN
State	:	NJ
Zip	:	07030-5626
Country	:	US
Telephone Number	:	201-244-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	09/10/2019

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