Provider Demographics
NPI:1588628184
Name:MADDUX, JACKSON W Q (MD)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:W Q
Last Name:MADDUX
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 1:800 E 28TH ST STE 1750
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3723
Mailing Address - Country:US
Mailing Address - Phone:612-863-4495
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST STE 1750
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407
Practice Address - Country:US
Practice Address - Phone:612-863-4495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0043168208100000X
KY36055208100000X
MN56201208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
H47092Medicare UPIN
H47092Medicare UPIN
MN250001045Medicare PIN