Provider Demographics
NPI:1245498864
Name:JACKSON, AMANDA L (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
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 1:237 WILLIAM HOWARD TAFT, PHYS DIV
Mailing Address - Street 2:2ND FL, CBO2-3. ATTN: CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-585-2323
Mailing Address - Fax:513-585-4893
Practice Address - Street 1:2139 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-585-2323
Practice Address - Fax:513-585-4893
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01231207V00000X
OH35 123680207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100301430OtherMEDICAID
OH0103881OtherMEDICAID
IN201232150OtherMEDICAID