Active NPI
Mark D Jackson, MD
- Cardiovascular Disease Physician
- Peoria, IL
National Provider Identifier
1952331019
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Cardiovascular Disease Physician
- License
- 036082717
- Practice address
- 5405 N Knoxville Ave
Peoria, IL 61614 - Phone
- (309) 691-4410
- Fax
- (309) 589-2830
- NPI assigned
- Jul 4, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Cardiovascular Disease Physician | 207RC0000X | 036082717 | IL | Primary |
Addresses
Primary practice location
5405 N Knoxville Ave
Peoria, IL 61614
Mailing address
5405 N Knoxville Ave
Peoria, IL 61614
Phone (309) 691-4410
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036082717 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1151971200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1283212800000",
"number": "1952331019",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5405 N KNOXVILLE AVE",
"city": "PEORIA",
"state": "IL",
"postal_code": "61614",
"telephone_number": "309-691-4410",
"fax_number": "309-589-2830"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "5405 N KNOXVILLE AVE",
"city": "PEORIA",
"state": "IL",
"postal_code": "61614",
"telephone_number": "309-691-4410",
"fax_number": "309-589-2830"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "MARK",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-04",
"last_updated": "2010-08-31",
"status": "A"
},
"taxonomies": [
{
"code": "207RC0000X",
"taxonomy_group": "",
"desc": "Internal Medicine, Cardiovascular Disease",
"state": "IL",
"license": "036082717",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036082717",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Peoria, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 31, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.