Provider Demographics
NPI:1336123041
Name:DR MARILYN D JACKSON & ASSOCIATES LTD
Entity Type:Organization
Organization Name:DR MARILYN D JACKSON & ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-757-3100
Mailing Address - Street 1:PO BOX 1893
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60412-1893
Mailing Address - Country:US
Mailing Address - Phone:708-757-3100
Mailing Address - Fax:708-757-3272
Practice Address - Street 1:1705 E SAUK TRL
Practice Address - Street 2:
Practice Address - City:SAUK VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60411-4955
Practice Address - Country:US
Practice Address - Phone:708-757-3100
Practice Address - Fax:708-757-3272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01917207122300000X
IN12009402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1002324Medicaid