Provider Demographics
NPI:1649310632
Name:IAN T. JACKSON, M.D.
Entity type:Organization
Organization Name:IAN T. JACKSON, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICANDIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-465-5300
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:STE 205
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-5300
Mailing Address - Fax:248-465-5301
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:STE 205
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-5300
Practice Address - Fax:248-465-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty