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NPI Code Detail

MEDICARE: JAMES JACKSON D.O.

MEDICARE: JAMES JACKSON D.O.
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
1207Q00000XFamily Medicine Physician02001724AIN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1548251937
Entity Type Code : Individual
Provider Name (Legal Business Name) : JAMES JACKSON D.O.
Provider Business Mailing Address
First Line : 236 SIMPSON AVE
Second Line :
City : ELKHART
State : IN
Zip : 46516-4666
Country : US
Telephone Number : 574-293-0052
Fax Number : 574-293-3744
Provider Business Practice Location Address
First Line : 236 SIMPSON AVE
Second Line :
City : ELKHART
State : IN
Zip : 46516-4666
Country : US
Telephone Number : 574-293-0052
Fax Number : 574-293-3744
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/03/2005
Last Update Date : 08/12/2016

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