Provider Demographics
NPI:1891782421
Name:JACKSON, THAD M (DO)
Entity Type:Individual
Prefix:DR
First Name:THAD
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1010 W NORTH DOWN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-2060
Mailing Address - Country:US
Mailing Address - Phone:989-348-7671
Mailing Address - Fax:989-348-8414
Practice Address - Street 1:1010 W NORTH DOWN RIVER RD
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-2060
Practice Address - Country:US
Practice Address - Phone:989-348-7671
Practice Address - Fax:989-348-8414
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MITJ013702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4303876Medicaid
MI4303876Medicaid