Provider Demographics
NPI:1457888950
Name:JACKMAN, JUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:JACKMAN
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 1:1508 KINGS RD
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2638
Mailing Address - Country:US
Mailing Address - Phone:562-777-6119
Mailing Address - Fax:
Practice Address - Street 1:2900 12TH AVE N STE 205W
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-7520
Practice Address - Country:US
Practice Address - Phone:406-254-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT74464207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty