Provider Demographics
NPI:1760814040
Name:JACKSON, MARVIN WILLIAM (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:WILLIAM
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
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Mailing Address - Street 1:2300 E DEVON AVE
Mailing Address - Street 2:SUITE 427
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4696
Mailing Address - Country:US
Mailing Address - Phone:847-294-7795
Mailing Address - Fax:847-294-7808
Practice Address - Street 1:2300 E DEVON AVE
Practice Address - Street 2:SUITE 427
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60018-4696
Practice Address - Country:US
Practice Address - Phone:847-294-7795
Practice Address - Fax:847-294-7808
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.1225822083A0100X
OH35.0851502083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine