Provider Demographics
NPI:1043650765
Name:JACKSON, DESMOND ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:DESMOND
Middle Name:ALEXANDER
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 1:501 S DRAKE RD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-3234
Mailing Address - Country:US
Mailing Address - Phone:269-344-5552
Mailing Address - Fax:
Practice Address - Street 1:501 S DRAKE RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-3234
Practice Address - Country:US
Practice Address - Phone:269-308-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.027945207R00000X
MI4301103154207RR0500X, 207RR0500X
MI430110154207RR0500X
MI430113154207RR0500X
OH390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program