Provider Demographics
NPI:1568821320
Name:JACKSON, MARCUS
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DBA: MLJ
Other - Middle Name:
Other - Last Name:ENTERPRISES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 224221
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75222-4221
Mailing Address - Country:US
Mailing Address - Phone:888-699-8985
Mailing Address - Fax:972-525-5388
Practice Address - Street 1:14785 PRESTON RD
Practice Address - Street 2:SUITE 550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-7876
Practice Address - Country:US
Practice Address - Phone:888-699-8985
Practice Address - Fax:972-525-5388
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator