Provider Demographics
NPI:1801365382
Name:JACKSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-0326
Mailing Address - Country:US
Mailing Address - Phone:208-890-9750
Mailing Address - Fax:
Practice Address - Street 1:5537B N GLENWOOD ST STE B
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1336
Practice Address - Country:US
Practice Address - Phone:208-789-9075
Practice Address - Fax:208-917-2818
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies