MEDICARE: DR MARILYN D JACKSON & ASSOCIATES LTD

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	122300000X	Dentist	12009402	IN
2	122300000X	Dentist	01917207	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336123041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR MARILYN D JACKSON & ASSOCIATES LTD

Provider Business Mailing Address
First Line	:	PO BOX 1893
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60412-1893
Country	:	US
Telephone Number	:	708-757-3100
Fax Number	:	708-757-3272

Provider Business Practice Location Address
First Line	:	1705 E SAUK TRL
Second Line	:
City	:	SAUK VILLAGE
State	:	IL
Zip	:	60411-4955
Country	:	US
Telephone Number	:	708-757-3100
Fax Number	:	708-757-3272

Authorized Official
Title or Position	:	DENTIST PRESIDENT OF CORPORATION
Name	:	MARILYN DENISE JACKSON
Credential	:	DDS
Telephone Number	:	708-757-3100

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	08/22/2020

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