MEDICARE: ERICA JACKSON

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	171M00000X	Case Manager/Care Coordinator
2	172A00000X	Driver
3	101YM0800X	Mental Health Counselor	296888	KY

General Provider Information

NPI Number	:	1558916577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA JACKSON

Provider Business Mailing Address
First Line	:	11103 INDIAN LEGENDS DR APT 202
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40241-3488
Country	:	US
Telephone Number	:	859-539-3683
Fax Number	:

Provider Business Practice Location Address
First Line	:	451 BAXTER AVE STE 201
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1177
Country	:	US
Telephone Number	:	502-383-2969
Fax Number	:

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

Provider Enumeration Date	:	08/06/2019
Last Update Date	:	05/16/2025

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