Provider Demographics
NPI:1891781969
Name:PEMBERTON, JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:
Last Name:PEMBERTON
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:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-301-2018
Mailing Address - Fax:859-301-2073
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2018
Practice Address - Fax:859-301-2073
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25835207ZP0101X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2463507Medicaid
KY64258353Medicaid
KY0655094Medicare PIN
KY3313164Medicare PIN
KY3400178Medicare PIN
C69427Medicare UPIN
KY220020954Medicare PIN