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1013533926

NPI Code Detail

MEDICARE: COURTNEY MARIE JACKSON MD

MEDICARE: COURTNEY MARIE JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01088399A	IN
2	207Q00000X	Family Medicine Physician	11021251A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	068010931	OTHER	IN	MEDICARE PTAN
2	266430813	OTHER		MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013533926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY MARIE JACKSON MD

Provider Business Mailing Address
First Line	:	11109 PARKVIEW PLAZA DR # 117
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-1701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6507 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7026
Country	:	US
Telephone Number	:	260-486-3300
Fax Number	:	260-485-3600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	12/11/2025

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Directions to “ COURTNEY MARIE JACKSON MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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