Provider Demographics
NPI:1982640090
Name:JACKSON, GREGORY R (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
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:PO BOX 4460
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104
Mailing Address - Country:US
Mailing Address - Phone:866-491-5807
Mailing Address - Fax:913-491-0411
Practice Address - Street 1:800 MERCY HOSPITAL
Practice Address - Street 2:ALEGENT MERCY HOSPITAL
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503
Practice Address - Country:US
Practice Address - Phone:712-328-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE170502085R0202X
IA260562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4043109Medicaid
IA41360OtherBCBS
IA5043109Medicaid
IA8043109Medicaid
NE17050OtherLICENSE #
207OtherMIDLANDS
26056OtherIA LICENSE #
NE35534OtherBCBS
AJ2110310OtherIA CONTROLLED SUBSTANCE
IA7043109Medicaid
IA6043109Medicaid
IA6043109Medicaid
NE300124120Medicare PIN
NENA1356019Medicare PIN
IA4043109Medicaid
207OtherMIDLANDS
AJ2110310OtherIA CONTROLLED SUBSTANCE
IA5043109Medicaid
IA8043109Medicaid