Provider Demographics
NPI:1053462986
Name:MARILYN M. JACKSON, M.D., M.P.H., PLLC
Entity Type:Organization
Organization Name:MARILYN M. JACKSON, M.D., M.P.H., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-549-5268
Mailing Address - Street 1:421 W 57TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1763
Mailing Address - Country:US
Mailing Address - Phone:212-247-8023
Mailing Address - Fax:212-247-8024
Practice Address - Street 1:421 W 57TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1763
Practice Address - Country:US
Practice Address - Phone:212-247-8023
Practice Address - Fax:212-247-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01447254Medicaid
NYWANW41Medicare PIN
NYF65129Medicare UPIN