Healthcare Provider Details

I. General information

NPI: 1194967604
Provider Name (Legal Business Name): KYLE WILLIAM JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR ROC 4340
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

PO BOX 719094
CHICAGO IL
60677-9318
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2143
  • Fax: 317-944-3107
Mailing address:
  • Phone: 317-777-6435
  • Fax: 317-777-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01078900A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number01078900
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: