Provider Demographics
NPI:1255374716
Name:JACKSON, MAX (MD)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 KUENZLI ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1011
Mailing Address - Country:US
Mailing Address - Phone:775-982-4590
Mailing Address - Fax:775-982-4595
Practice Address - Street 1:850 MILL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1413
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5417
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR3H65207Q00000X
NV12030207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP53D122Medicare ID - Type UnspecifiedMEDICARE B - GOPPERT
MOP52D122Medicare ID - Type UnspecifiedMEDICARE B TRINITY