Provider Demographics
NPI:1114922911
Name:JACKSON, JOHN RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RONALD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-341-2510
Mailing Address - Fax:859-578-2004
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:STE 302
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5402
Practice Address - Country:US
Practice Address - Phone:859-341-2510
Practice Address - Fax:859-578-5888
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35. 073600207V00000X
KY34447207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3003565Medicaid
KY7100093740Medicaid
KY0045510Medicare ID - Type UnspecifiedFLORENCE OFFICE
KYH24913Medicare UPIN
KY0022912Medicare ID - Type UnspecifiedEDGEWOOD OFFICE
OH3003565Medicaid
KY00954035Medicare PIN