Provider Demographics
NPI:1023246949
Name:JACKSON, AMIE ELISSA (MD)
Entity type:Individual
Prefix:DR
First Name:AMIE
Middle Name:ELISSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NICHOLASVILLE RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1466
Mailing Address - Country:US
Mailing Address - Phone:859-276-0414
Mailing Address - Fax:859-276-3765
Practice Address - Street 1:1700 NICHOLASVILLE RD STE 1100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1466
Practice Address - Country:US
Practice Address - Phone:859-276-0414
Practice Address - Fax:859-276-3765
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56752207RH0003X
MN106237207RH0003X
MN55653207RH0003X
OH35.123128207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100622180Medicaid
IAENROLLEDMedicaid
SDENROLLEDMedicaid
MNENROLLEDMedicaid