Provider Demographics
NPI:1629186242
Name:JACKSON, THOMAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:C
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:1020 N 12TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-219-7136
Practice Address - Fax:414-219-6294
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI17097207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30918800Medicaid
AJ4880666OtherDEA NUMBER
AJ4880666OtherDEA NUMBER