Organization
MARK A JACKSON MD PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MARK A JACKSON MD (PHYSICIAN/OWNER)
(231) 935-0913
Entity
Organization
Contact information
Practice address
1000 PAVILLIONS CIR, TRAVERSE CITY, MI 49684-3198
(231) 935-0913
(231) 935-0984
Mailing address
PO BOX 1267, TRAVERSE CITY, MI 49685-1267
(231) 935-0913
(231) 935-0984
Taxonomy
Speciality
Code
Description
License number
State
207QG0300X
Geriatric Medicine (Family Medicine) Physician
Primary
4301051555
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0802802421
BCBS PIN#
MI
01
—
080B813500
BCBS ID#
MI
01
—
0B81350
BCBS GROUP ID#
MI
01
—
0MI1114
MEDICARE GROUP
MI
01
—
1073585238
IND NPI
MI
05
—
1073585238
—
MI
01
—
1740439025
GROUP NPI
MI
01
—
MI1114001
MEDICARE IND PTAN
MI
Enumeration date
09/11/2008
Last updated
12/18/2008
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