Provider Demographics
NPI:1265887210
Name:JACKSON SLEEP CENTERS PLLC
Entity type:Organization
Organization Name:JACKSON SLEEP CENTERS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:810-664-4641
Mailing Address - Street 1:454 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2427
Mailing Address - Country:US
Mailing Address - Phone:810-664-4641
Mailing Address - Fax:810-272-4293
Practice Address - Street 1:11825 STATE ROUTE 40
Practice Address - Street 2:SUITE 100
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8842
Practice Address - Country:US
Practice Address - Phone:309-839-9971
Practice Address - Fax:309-807-3365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901009946122300000X
MI2901021258122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty