Provider Demographics
NPI:1851329197
Name:JACKSON, AVERY MICHAEL III (MD)
Entity Type:Individual
Prefix:DR
First Name:AVERY
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4620 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8067
Mailing Address - Country:US
Mailing Address - Phone:810-606-7200
Mailing Address - Fax:810-606-7115
Practice Address - Street 1:9400 S SAGINAW RD STE A
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-9666
Practice Address - Country:US
Practice Address - Phone:810-606-7200
Practice Address - Fax:810-606-7115
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MIAJ076974207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0993708OtherHEALTHPLUS OF MICHIGAN
MI4568263Medicaid
MI4568263Medicaid
MIH16288Medicare UPIN