Provider Demographics
NPI:1124523899
Name:JACKSON, MARCUS DIOR
Entity type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:DIOR
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 TREMONT ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-7604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1913 TREMONT ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-7604
Practice Address - Country:US
Practice Address - Phone:202-294-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care