Provider Demographics
NPI:1912947631
Name:JACKSON, JESSICA (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15014 BIRCHAM RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4104
Mailing Address - Country:US
Mailing Address - Phone:502-558-0194
Mailing Address - Fax:
Practice Address - Street 1:2315 GREEN VALLEY RD STE 200
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4690
Practice Address - Country:US
Practice Address - Phone:502-558-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00242213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80002421Medicaid
IN200279930Medicaid
KYP00696482OtherRAILROAD MEDICARE
KYP00696482OtherRAILROAD MEDICARE
KY008580001Medicare PIN