Provider Demographics
NPI:1205830007
Name:JACKSON, JAMES MARK (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARK
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:866-630-9882
Mailing Address - Fax:920-682-5810
Practice Address - Street 1:501 S 2ND ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1864
Practice Address - Country:US
Practice Address - Phone:502-583-7546
Practice Address - Fax:502-589-3429
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01085873A207N00000X
TXJ8602207N00000X
KY31633207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G45194Medicare UPIN
KY0381304Medicare PIN
KY64316334Medicaid
070013597OtherRR MEDICARE