Provider Demographics
NPI:1831127208
Name:JACKSON, JAMES W (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
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 189
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-0189
Mailing Address - Country:US
Mailing Address - Phone:812-265-0820
Mailing Address - Fax:812-265-0570
Practice Address - Street 1:630 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3310
Practice Address - Country:US
Practice Address - Phone:812-265-0820
Practice Address - Fax:812-265-0570
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021515207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1096355OtherPASSPORT KY MEDICAID
060055388OtherMEDICARE RAILROAD
5412546OtherAETNA
KY64337330Medicaid
IN000000210998OtherANTHEM BCBS
IN200149120AMedicaid
KY2436127000OtherPASSPORT ADVANTAGE
KY2436127000OtherPASSPORT ADVANTAGE
060055388OtherMEDICARE RAILROAD
IN412800DMedicare PIN
IN412800DMedicare ID - Type Unspecified