Provider Demographics
NPI:1134125123
Name:JACKSON, ROSALIND J (MD)
Entity Type:Individual
Prefix:
First Name:ROSALIND
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-384-4841
Mailing Address - Fax:937-384-4845
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:STE. 200
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-293-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071571207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH160056974OtherMEDICARE RAILROAD
OH000000275787OtherANTHEM
OH2789692OtherAETNA
OH2238322Medicaid
OH160056974OtherMEDICARE RAILROAD
OH4050792Medicare PIN