Provider Demographics
NPI:1528289881
Name:JACKSON, MARK (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:10 RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0179
Mailing Address - Country:US
Mailing Address - Phone:701-854-3831
Mailing Address - Fax:701-854-7411
Practice Address - Street 1:10 STANDING ROCK AGENCY AVENUE
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:701-854-7411
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0122112083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEC24405Medicare UPIN
ND8HH607Medicare PIN
SD8HH608Medicare PIN