MEDICARE: DR. MICHAEL E. 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	207N00000X	Dermatology Physician	177618-1	NY

General Provider Information

NPI Number	:	1912991019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL E. JACKSON M.D.

Provider Business Mailing Address
First Line	:	55 GREENE AVE
Second Line	:	SUITES 2D/2E
City	:	BROOKLYN
State	:	NY
Zip	:	11238
Country	:	US
Telephone Number	:	718-623-2783
Fax Number	:	718-623-2787

Provider Business Practice Location Address
First Line	:	55 GREENE AVE 2D/2E
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238-6406
Country	:	US
Telephone Number	:	718-623-2783
Fax Number	:	718-623-2787

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	09/04/2015

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