Provider Demographics
NPI:1013167444
Name:JACKSON FAMILY MEDICAL PLLC
Entity Type:Organization
Organization Name:JACKSON FAMILY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LAVERNE
Authorized Official - Last Name:LYND
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:517-784-3100
Mailing Address - Street 1:724 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2008
Mailing Address - Country:US
Mailing Address - Phone:517-784-3100
Mailing Address - Fax:517-784-3200
Practice Address - Street 1:724 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2008
Practice Address - Country:US
Practice Address - Phone:517-784-3100
Practice Address - Fax:517-784-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-22
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5409Medicare PIN