Individual
JACKSON MARK BENNETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
2355 HWY 36 W, STE 100, ROSEVILLE, MN 55113
(651) 292-2000
Mailing address
2355 HWY 36 W, STE 100, ROSEVILLE, MN 55113
(651) 292-2000
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
24149
ND
2085R0202X
Diagnostic Radiology Physician
Primary
77424
WI
2085R0202X
Diagnostic Radiology Physician
81981
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1366070328
—
WI
Enumeration date
03/27/2020
Last updated
07/07/2026
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