Provider Demographics
NPI:1003877077
Name:JACKSON, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1474 E ERDA WAY
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9737
Mailing Address - Country:US
Mailing Address - Phone:435-849-0779
Mailing Address - Fax:
Practice Address - Street 1:1474 E ERDA WAY
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9737
Practice Address - Country:US
Practice Address - Phone:435-849-0779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5929640-1205207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6378Medicaid
UTG78689Medicare UPIN
UT005568644Medicare ID - Type Unspecified1050 E SOUTH TEMPLE, SLC
UT005786129Medicare ID - Type Unspecified2055 N MAIN, TOOELE