Provider Demographics
NPI:1184602666
Name:JACKSON, ORLAN (DO)
Entity type:Individual
Prefix:MR
First Name:ORLAN
Middle Name:
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 1:1312 HIGHWAY 49 N
Mailing Address - Street 2:
Mailing Address - City:BEULAH
Mailing Address - State:ND
Mailing Address - Zip Code:58523-6038
Mailing Address - Country:US
Mailing Address - Phone:701-873-4445
Mailing Address - Fax:701-873-4199
Practice Address - Street 1:1312 HIGHWAY 49 N
Practice Address - Street 2:
Practice Address - City:BEULAH
Practice Address - State:ND
Practice Address - Zip Code:58523-6038
Practice Address - Country:US
Practice Address - Phone:701-873-4445
Practice Address - Fax:701-873-4199
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND5650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13470Medicaid
ND27705OtherBLUE CROSS BLUE SHIELD ND
ND27705OtherBLUE CROSS BLUE SHIELD ND
ND13470Medicaid