Provider Demographics
NPI:1740439025
Name:MARK A JACKSON MD PLC
Entity type:Organization
Organization Name:MARK A JACKSON MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-0913
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-1267
Mailing Address - Country:US
Mailing Address - Phone:231-935-0913
Mailing Address - Fax:231-935-0984
Practice Address - Street 1:1000 PAVILLIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3198
Practice Address - Country:US
Practice Address - Phone:231-935-0913
Practice Address - Fax:231-935-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051555207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B81350OtherBCBS GROUP ID#
MI1073585238OtherIND NPI
MI0802802421OtherBCBS PIN#
MI080B813500OtherBCBS ID#
MI1740439025OtherGROUP NPI
MI0MI1114OtherMEDICARE GROUP
MI1073585238Medicaid
MIMI1114001OtherMEDICARE IND PTAN
MI0802802421OtherBCBS PIN#
MI0MI1114OtherMEDICARE GROUP
MIMI1114Medicare PIN