Healthcare Provider Details

I. General information

NPI: 1538370846
Provider Name (Legal Business Name): SHA-RON JACKSON-JOHNSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHA-RON JACKSON MD

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E 87TH AVE SUITE 420
MERRILLVILLE IN
46410-7335
US

IV. Provider business mailing address

7895 GRAND BLVD
HOBART IN
46342-6665
US

V. Phone/Fax

Practice location:
  • Phone: 219-769-2041
  • Fax: 219-769-2313
Mailing address:
  • Phone: 219-947-1910
  • Fax: 219-947-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57010730
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number35 123453
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01076732A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: