Provider Demographics
NPI:1477511921
Name:JACKSON, MORRIS B (MD)
Entity Type:Individual
Prefix:
First Name:MORRIS
Middle Name:B
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 1:101 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3769
Mailing Address - Country:US
Mailing Address - Phone:812-282-3899
Mailing Address - Fax:812-282-4172
Practice Address - Street 1:3920 S DUPONT SQ STE C
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4615
Practice Address - Country:US
Practice Address - Phone:812-282-3899
Practice Address - Fax:812-282-4172
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22181208800000X
IN01039636A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64221815Medicaid
IN201028460Medicaid
KYP00314088OtherRAILROAD MEDICARE
KY00895267OtherRAILROAD MEDICARE
KY64221815Medicaid
INM400040555Medicare PIN
KY0998215Medicare PIN
A82472Medicare UPIN