Provider Demographics
NPI:1699745273
Name:JACKSON, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1819 W CLINCH AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2434
Mailing Address - Country:US
Mailing Address - Phone:865-523-6418
Mailing Address - Fax:865-523-6587
Practice Address - Street 1:1819 W CLINCH AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2434
Practice Address - Country:US
Practice Address - Phone:865-523-6418
Practice Address - Fax:865-523-6587
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-02-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TNMD28432207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND40230Medicare UPIN
TN3805422Medicare ID - Type Unspecified