Provider Demographics
NPI:1659536076
Name:HERSHEL C JACKSON MD PC
Entity Type:Organization
Organization Name:HERSHEL C JACKSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HERSHEL
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-559-8810
Mailing Address - Street 1:23077 GREENFIELD RD
Mailing Address - Street 2:#450
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-599-8810
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:#450
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-599-8810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAJ043930207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC BSOther0635321
MI287072310Medicaid
A75110Medicare UPIN