MEDICARE: DR. JESSICA JACKSON DPM

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	213E00000X	Podiatrist	00242	KY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00696482	OTHER	KY	RAILROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1912947631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA JACKSON DPM

Provider Business Mailing Address
First Line	:	15014 BIRCHAM RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40245-4104
Country	:	US
Telephone Number	:	502-558-0194
Fax Number	:

Provider Business Practice Location Address
First Line	:	2315 GREEN VALLEY RD STE 200
Second Line	:
City	:	NEW ALBANY
State	:	IN
Zip	:	47150-4690
Country	:	US
Telephone Number	:	502-558-0194
Fax Number	:

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

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/04/2021

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