Healthcare Provider Details

I. General information

NPI: 1609444967
Provider Name (Legal Business Name): JACOB STAFFORD EDMISSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2021
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 BARNHILL DR
INDIANAPOLIS IN
46202-5116
US

IV. Provider business mailing address

535 BARNHILL DR
INDIANAPOLIS IN
46202-5116
US

V. Phone/Fax

Practice location:
  • Phone: 317-948-6942
  • Fax:
Mailing address:
  • Phone: 317-948-6942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11023782A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021021803
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: