Provider Demographics
NPI:1134380694
Name:JACKSON, THOMAS MICHAEL (DO)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 BITTERROOT ROAD
Mailing Address - Street 2:PO BOX 47
Mailing Address - City:CARMEN
Mailing Address - State:ID
Mailing Address - Zip Code:83462
Mailing Address - Country:US
Mailing Address - Phone:208-756-8047
Mailing Address - Fax:
Practice Address - Street 1:7 BITTERROOT ROAD
Practice Address - Street 2:
Practice Address - City:CARMEN
Practice Address - State:ID
Practice Address - Zip Code:83462
Practice Address - Country:US
Practice Address - Phone:208-756-8047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID021207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine