Provider Demographics
NPI:1902958929
Name:JACKSON, MITCHELL ALIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ALIN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 N MILWAUKEE AVE
Mailing Address - Street 2:SUITE L JACKSONEYE SC
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-356-0700
Mailing Address - Fax:847-356-0757
Practice Address - Street 1:300 N MILWAUKEE AVE
Practice Address - Street 2:SUITE L JACKSONEYE SC
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-356-0700
Practice Address - Fax:847-356-0757
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083377207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0004932263OtherBCBS #
IL208201OtherMEDICARE ID
IL036083377Medicaid
K03573Medicare PIN
IL0004932263OtherBCBS #