Provider Demographics
NPI:1427052091
Name:JACKSON, JAMES LAWRENCE (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LAWRENCE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 JOSEPH DR STE B
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-8636
Mailing Address - Country:US
Mailing Address - Phone:989-631-2020
Mailing Address - Fax:
Practice Address - Street 1:400 JOSEPH DR STE B
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-8636
Practice Address - Country:US
Practice Address - Phone:989-631-2020
Practice Address - Fax:989-835-6686
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050635207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1805601441OtherBCBS
MI1427052091OtherNPI
MI180032321OtherRAILROAD MEDICARE
MI0256160001OtherDMERC - MEDICARE
MI104430921OtherMEDICAID (GLADWIN OFFICE)
MI3103914Medicaid
MI104430921OtherMEDICAID (GLADWIN OFFICE)
MIE64530002Medicare PIN
MI180032321OtherRAILROAD MEDICARE