Provider Demographics
NPI:1275507311
Name:JACKSON, JENNIFER L (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 WASHINGTON VILLAGE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459
Mailing Address - Country:US
Mailing Address - Phone:937-438-0099
Mailing Address - Fax:937-438-0902
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-438-3132
Practice Address - Fax:937-438-8707
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007638207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2466291Medicaid
OHJA4131701Medicare PIN
OHJA4131704Medicare PIN
OHJA7325471Medicare PIN
OHJA4131702Medicare PIN
OH2466291Medicaid
OHJA4131703Medicare PIN