Provider Demographics
NPI:1033179338
Name:JACKNIN, MARK AARON (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:AARON
Last Name:JACKNIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746087
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6087
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:4405 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4014
Practice Address - Country:US
Practice Address - Phone:212-740-2020
Practice Address - Fax:646-666-0280
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230171207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02716663Medicaid
NYI44907Medicare UPIN
NY3125P1Medicare ID - Type UnspecifiedPROVIDER NUMBER