Provider Demographics
NPI:1881675080
Name:JACKSON, J. PHILLIP (MD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:PHILLIP
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 1:3534 BROOKLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1361
Mailing Address - Country:US
Mailing Address - Phone:260-747-6171
Mailing Address - Fax:260-478-5125
Practice Address - Street 1:7980 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4170
Practice Address - Country:US
Practice Address - Phone:260-436-9454
Practice Address - Fax:260-436-7836
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037752A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000892OtherMPLAN
1431OtherPHYSICIANS HEALTH PLAN
IN080121955OtherRAILROAD MEDICARE
000000091890OtherBLUE CROSS BLUE SHIELD
IN100462820Medicaid
IN080121955OtherRAILROAD MEDICARE
000000091890OtherBLUE CROSS BLUE SHIELD
E11385Medicare UPIN
INM400048217Medicare PIN