MEDICARE: MARK A JACKSON MD PLC

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	4301051555	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	0MI1114	OTHER	MI	MEDICARE GROUP
8	MI1114001	OTHER	MI	MEDICARE IND PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0B81350	OTHER	MI	BCBS GROUP ID#
2	1073585238	OTHER	MI	IND NPI
3	0802802421	OTHER	MI	BCBS PIN#
4	080B813500	OTHER	MI	BCBS ID#
5	1740439025	OTHER	MI	GROUP NPI
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740439025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK A JACKSON MD PLC

Provider Business Mailing Address
First Line	:	PO BOX 1267
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49685-1267
Country	:	US
Telephone Number	:	231-935-0913
Fax Number	:	231-935-0984

Provider Business Practice Location Address
First Line	:	1000 PAVILLIONS CIR
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-3198
Country	:	US
Telephone Number	:	231-935-0913
Fax Number	:	231-935-0984

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. MARK A JACKSON
Credential	:	MD
Telephone Number	:	231-935-0913

Provider Enumeration Date	:	09/11/2008
Last Update Date	:	12/18/2008

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