Provider Demographics
NPI:1245062900
Name:JACKSON, MARCUS
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4954 E 56TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-5769
Mailing Address - Country:US
Mailing Address - Phone:317-941-7387
Mailing Address - Fax:
Practice Address - Street 1:4954 E 56TH ST STE 4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-5769
Practice Address - Country:US
Practice Address - Phone:317-941-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker