Provider Demographics
NPI:1609851443
Name:JACKSON, MARY J (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:308 W SENECA ST
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104-2318
Practice Address - Country:US
Practice Address - Phone:315-682-5080
Practice Address - Fax:315-682-8847
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY154924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD02331Medicare UPIN
NY080094865Medicare PIN
NY56100IMedicare PIN