Provider Demographics
NPI:1659590735
Name:JACKSON, MICHAEL DONIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DONIEL
Last Name:JACKSON
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 1:2910 WESTOWN PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1332
Mailing Address - Country:US
Mailing Address - Phone:515-223-7773
Mailing Address - Fax:402-939-0407
Practice Address - Street 1:2910 WESTOWN PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1332
Practice Address - Country:US
Practice Address - Phone:515-223-7773
Practice Address - Fax:402-939-0407
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA37062208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIN PROCESSMedicaid
IAIN PROCESSMedicaid