Provider Demographics
NPI:1043272974
Name:JACKSON, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
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 1:1456 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2607
Mailing Address - Country:US
Mailing Address - Phone:718-636-4500
Mailing Address - Fax:341-729-6836
Practice Address - Street 1:1456 FULTON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-2607
Practice Address - Country:US
Practice Address - Phone:718-636-4500
Practice Address - Fax:341-729-6836
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY181595207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine