Provider Demographics
NPI:1790956837
Name:JACKSON OB-GYN PLC
Entity Type:Organization
Organization Name:JACKSON OB-GYN PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-787-0334
Mailing Address - Street 1:306 W WASHINGTON
Mailing Address - Street 2:STE 102
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201
Mailing Address - Country:US
Mailing Address - Phone:517-787-0334
Mailing Address - Fax:
Practice Address - Street 1:306 W WASHINGTON
Practice Address - Street 2:STE 102
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201
Practice Address - Country:US
Practice Address - Phone:517-787-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012522207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty