Provider Demographics
NPI:1073585238
Name:JACKSON, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10850 E TRAVERSE HWY
Mailing Address - Street 2:STE 4400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-1364
Mailing Address - Country:US
Mailing Address - Phone:231-346-6930
Mailing Address - Fax:231-346-6017
Practice Address - Street 1:1000 PAVILIONS CIRCLE
Practice Address - Street 2:MARK A JACKSON MD PLC
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-935-0913
Practice Address - Fax:231-935-0984
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2015-10-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI051555207Q00000X
MI4301051555207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1820487Medicaid
MA080B86010OtherBLUE SHIELD
MI1820487Medicaid
MIB43877Medicare UPIN
MA080B86010OtherBLUE SHIELD