Provider Demographics
NPI:1427259191
Name:JACKMAN, TODD EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:EDWARD
Last Name:JACKMAN
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 1:1950 NORTHWESTERN AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7615
Mailing Address - Country:US
Mailing Address - Phone:651-430-3800
Mailing Address - Fax:651-430-3827
Practice Address - Street 1:7373 FRANCE AVE S STE 408
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4549
Practice Address - Country:US
Practice Address - Phone:651-430-3800
Practice Address - Fax:651-430-3827
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47215207XS0117X
WAMD00049377207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8876642OtherMEDICARE EMRI
WAP00689386OtherMEDICARE RR KING CO.
WAG8876017OtherMEDICARE POSM
WA0238823OtherL & I