Basic Information
| Provider Information | |||||||||
| NPI: | 1598084691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Practice Location | |||||||||
| Address1: | 5515 CLEVELAND AVE | ||||||||
| Address2: | |||||||||
| City: | STEVENSVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491279670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694299644 | ||||||||
| FaxNumber: | 2694294002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2010 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 51389 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 47055 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P1331 | TX | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 4301108841 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.