Provider Demographics
NPI:1477860757
Name:JACKSON, MARK ALLAN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISA
Mailing Address - State:KY
Mailing Address - Zip Code:41230-1316
Mailing Address - Country:US
Mailing Address - Phone:506-638-3234
Mailing Address - Fax:
Practice Address - Street 1:322 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LOUISA
Practice Address - State:KY
Practice Address - Zip Code:41230-1316
Practice Address - Country:US
Practice Address - Phone:506-638-3234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other