Mark a Jackson MD PLC

Primary specialty

Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X

License

4301051555 Issued in MI

Legal business name

MARK A JACKSON MD PLC

Practice address

1000 Pavillions Cir
Traverse City, MI 49684-3198

Phone

(231) 935-0913

Fax

(231) 935-0984

NPI assigned

Sep 11, 2008

Organization subpart

No

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

Authorized official

Name

Dr. Mark A Jackson, MD

Title

Physician/Owner

Phone

(231) 935-0913

Specialties & licenses 1

Addresses

Other identifiers 8

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

{
    "created_epoch": "1221091200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1229558400000",
    "number": "1740439025",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1267",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496851267",
            "telephone_number": "231-935-0913",
            "fax_number": "231-935-0984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1000 PAVILLIONS CIR",
            "city": "TRAVERSE CITY",
            "state": "MI",
            "postal_code": "496843198",
            "telephone_number": "231-935-0913",
            "fax_number": "231-935-0984"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARK A JACKSON MD PLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-09-11",
        "last_updated": "2008-12-18",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "PHYSICIAN/OWNER",
        "authorized_official_telephone_number": "231-935-0913",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "MI",
            "license": "4301051555",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS GROUP ID#",
            "identifier": "0B81350",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "IND NPI",
            "identifier": "1073585238",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS PIN#",
            "identifier": "0802802421",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS ID#",
            "identifier": "080B813500",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "GROUP NPI",
            "identifier": "1740439025",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP",
            "identifier": "0MI1114",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1073585238",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE IND PTAN",
            "identifier": "MI1114001",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Geriatric Medicine (Family Medicine) Physician in Traverse City, MI
• Providers in Traverse City, MI by specialty
• Geriatric Medicine (Family Medicine) Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.