Provider Demographics
NPI:1467819920
Name:JACKSON FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:JACKSON FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-577-9181
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-0190
Mailing Address - Country:US
Mailing Address - Phone:740-577-9181
Mailing Address - Fax:740-577-9214
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:SUITE 260
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-9360
Practice Address - Country:US
Practice Address - Phone:740-577-9181
Practice Address - Fax:740-577-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H422750Medicare PIN