MEDICARE: DR. THOMAS L JACKSON M.D.

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	174400000X	Specialist	01046379A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01046379A	OTHER	IN	STATE LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154308997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS L JACKSON M.D.

Provider Business Mailing Address
First Line	:	2450 N PARK DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-2292
Country	:	US
Telephone Number	:	812-376-8997
Fax Number	:	812-373-5323

Provider Business Practice Location Address
First Line	:	2450 N PARK DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-2216
Country	:	US
Telephone Number	:	812-376-8997
Fax Number	:	812-373-5323

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

Provider Enumeration Date	:	12/22/2005
Last Update Date	:	08/02/2010

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