Provider Demographics
NPI:1811995996
Name:DAVID L. JACKSON, M.D., PSC
Entity type:Organization
Organization Name:DAVID L. JACKSON, M.D., PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-367-7110
Mailing Address - Street 1:2050 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-1405
Mailing Address - Country:US
Mailing Address - Phone:859-367-7110
Mailing Address - Fax:859-367-7138
Practice Address - Street 1:2050 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1405
Practice Address - Country:US
Practice Address - Phone:859-367-7110
Practice Address - Fax:859-367-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24005208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2300002OtherUNITED HEALTHCARE PIN
KY65925463Medicaid
KYC66084OtherBLUEGRASS FAMILY HEALTH
KY000000050829OtherANTHEM B/C & B/S PIN
KYC66084OtherBLUEGRASS FAMILY HEALTH
KYC66084Medicare UPIN