Provider Demographics
NPI:1558516054
Name:JESSICA S JACKSON DPM PLLC
Entity Type:Organization
Organization Name:JESSICA S JACKSON DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-558-0194
Mailing Address - Street 1:15014 BIRCHAM RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4104
Mailing Address - Country:US
Mailing Address - Phone:502-558-0194
Mailing Address - Fax:
Practice Address - Street 1:15014 BIRCHAM RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4104
Practice Address - Country:US
Practice Address - Phone:502-558-0194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-25
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00242213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100071060Medicaid
IN201083640AMedicaid
KYDO6474OtherRAILROAD MEDICARE
KY00858Medicare PIN
KY7100071060Medicaid