Healthcare Provider Details

I. General information

NPI: 1114307766
Provider Name (Legal Business Name): CHRISTINA LYNN JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

2625 N MERIDIAN ST APT 515
INDIANAPOLIS IN
46208-7705
US

V. Phone/Fax

Practice location:
  • Phone: 317-745-4451
  • Fax: 317-718-6740
Mailing address:
  • Phone: 219-242-5680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11018154A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01078911A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: