Provider Demographics
NPI:1548656937
Name:JACKSON, MARKUS (MD)
Entity type:Individual
Prefix:
First Name:MARKUS
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:PO BOX 27345
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2025
Mailing Address - Country:US
Mailing Address - Phone:209-571-0288
Mailing Address - Fax:209-571-0327
Practice Address - Street 1:4016 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9268
Practice Address - Country:US
Practice Address - Phone:209-571-0288
Practice Address - Fax:209-571-0327
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA165519207L00000X, 208VP0000X, 208VP0014X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program