Provider Demographics
NPI:1487637922
Name:JACKSON, MICHAEL VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:VINCENT
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 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:236 W 6TH ST
Practice Address - Street 2:STE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4517
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3900
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4867207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002016249Medicaid
D35455Medicare UPIN
NV002016249Medicaid