Provider Demographics
NPI:1437174638
Name:JACKSON, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
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 1:26650 EUREKA RD
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4835
Mailing Address - Country:US
Mailing Address - Phone:734-941-4991
Mailing Address - Fax:734-941-4919
Practice Address - Street 1:2500 HAMLIN DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2348
Practice Address - Country:US
Practice Address - Phone:313-561-5100
Practice Address - Fax:313-565-0309
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301025901208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1020381OtherMCLAREN HEALTH PLAN HAN
MI17572OtherMCARE MMMI
MI350D410030OtherBCN BLUE CHOICE FENTON
MI700H228520OtherBCBSM
MI4737508Medicaid
MI1437174638OtherNPI
MI4859153Medicaid
MI0994622OtherHEALTH PLUS MMMI
MI350D410030OtherBCBS MMMI
MI4859153Medicaid
MI700H228520OtherBCBSM