NPIMap

Individual provider Active NPI

Jackson Mark Bennett

  • Diagnostic Radiology Physician
  • Roseville, MN
National Provider Identifier
1366070328
Registry record updated Jul 7, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
77424 Issued in WI
Practice address
2355 Hwy 36 W
Ste 100
Roseville, MN 55113
Phone
(651) 292-2000
NPI assigned
Mar 27, 2020
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 7, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 81981 MN
Diagnostic Radiology Physician 2085R0202X 77424 WI Primary
Diagnostic Radiology Physician 2085R0202X 24149 ND

Addresses

Primary practice location

2355 Hwy 36 W
Ste 100
Roseville, MN 55113

Mailing address

2355 Hwy 36 W
Ste 100
Roseville, MN 55113
Phone (651) 292-2000

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250514002925 WI Practitioner - Diagnostic Radiology 7113342148 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Diagnostic Radiology
Education
Baylor College of Medicine, 2020
Medicare assignment
May accept Medicare assignment

Practice addresses (Care Compare)

1000 N Oak Ave
Marshfield, WI 54449-5703

2355 Hwy 36 W
Suite 100
Roseville, MN 55113-3905

2355 Hwy 36 W 100
Roseville, MN 55113-3905

500 S Maple St
Waconia, MN 55387-1752

900 2ND Ave
Madison, MN 56256-1006

Hospital & facility affiliations

  • Froedtert Memorial Lutheran Hospital Hospital, Milwaukee, WI, CCN 520177
  • Community Memorial Hospital Hospital, Menomonee Falls, WI, CCN 520103
  • Froedtert Community Hospital Hospital, New Berlin, WI, CCN 520213
  • St Josephs Community Hospital West Bend Hospital, West Bend, WI, CCN 520063

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
77424WIMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
The Medical College of Wisconsin, Inc. CurrentSince Jul 1, 2025 Accepting new patients
Froedtert &the Medical College of Wisconsin Community Physicians, Inc. CurrentSince Jul 10, 2025 Accepting new patients
Froedtert &the Medical College of Wisconsin Community Physicians, Inc. CurrentSince Jul 10, 2025 Accepting new patients
Suburban Imaging, LLC CurrentSince Aug 31, 2026 Accepting new patients

Locations

8990 Springbrook Dr NW
Ste 140
Minneapolis, MN 55433
Phone (763) 792-1900

2355 Highway 36 W
Ste 100
Saint Paul, MN 55113
Phone (651) 292-0000

W168N11237 Western Ave
Germantown, WI 53022
Phone (262) 253-5060

N74W12501 Leatherwood Ct
Menomonee Falls, WI 53051
Phone (414) 454-4744

8701 Watertown Plank Rd
Wauwatosa, WI 53226
Phone (414) 456-4100

1155 N Mayfair Rd
Wauwatosa, WI 53226
Phone (414) 955-5990

9200 W Wisconsin Ave
Wauwatosa, WI 53226
Phone (414) 259-3000

Interoperability endpoints

  • Direct secure messaging: jbennett386930@direct.froedtert.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1585267200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1783382400000",
    "number": "1366070328",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2355 HWY 36 W",
            "address_2": "STE 100",
            "city": "ROSEVILLE",
            "state": "MN",
            "postal_code": "55113",
            "telephone_number": "651-292-2000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2355 HWY 36 W",
            "address_2": "STE 100",
            "city": "ROSEVILLE",
            "state": "MN",
            "postal_code": "55113",
            "telephone_number": "651-292-2000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BENNETT",
        "first_name": "JACKSON",
        "middle_name": "MARK",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-03-27",
        "last_updated": "2026-07-07",
        "certification_date": "2026-07-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "MN",
            "license": "81981",
            "primary": false
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "WI",
            "license": "77424",
            "primary": true
        },
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "ND",
            "license": "24149",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Roseville, MN

Sources for this page

Verify at the official NPI Registry.