1427259191 NPI number — DR. TODD EDWARD JACKMAN MD

Table of content: DR. TODD EDWARD JACKMAN MD (NPI 1427259191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427259191 NPI number — DR. TODD EDWARD JACKMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKMAN
Provider First Name:
TODD
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427259191
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 NORTHWESTERN AVE S STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STILLWATER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55082-7615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-430-3800
Provider Business Mailing Address Fax Number:
651-430-3827

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7373 FRANCE AVE S STE 408
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-4549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-430-3800
Provider Business Practice Location Address Fax Number:
651-430-3827
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  47215 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0117X , with the licence number: MD00049377 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G8876642 . This is a "MEDICARE EMRI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00689386 . This is a "MEDICARE RR KING CO." identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: G8876017 . This is a "MEDICARE POSM" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0238823 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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