Provider Demographics
NPI:1639359565
Name:JACKSON HEALTHCARE
Entity type:Organization
Organization Name:JACKSON HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-647-1958
Mailing Address - Street 1:148 MIDLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-9734
Mailing Address - Country:US
Mailing Address - Phone:502-647-1958
Mailing Address - Fax:502-647-1940
Practice Address - Street 1:148 MIDLAND BLVD
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-9734
Practice Address - Country:US
Practice Address - Phone:502-647-1958
Practice Address - Fax:502-647-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18425208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0747001Medicare PIN
KY7470Medicare PIN