Carly Anne Jackson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

324 Roxbury Rd
Rockford, IL 61107-5090

Phone

(815) 398-9491

Fax

(815) 381-7333

NPI assigned

Oct 12, 2011

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in OR

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Middlesex University School of Medicine, 2009

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Mid-Columbia Medical CenterGroup PAC ID 3779487251, 99 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Mid-Columbia Medical Center Hospital, The Dalles, OR, CCN 380001
• Klickitat Valley Hospital Hospital, Goldendale, WA, CCN 501316
• Ohsu Hospital and Clinics Hospital, Portland, OR, CCN 380009

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: cjackson108686@direct.ohsu.edu

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mid-Columbia Medical Center

  • General Practice Physician
  • The Dalles, OR
  • NPI 1053409599
  Medicare reassignment Care Compare group NPD
• Mid-Columbia Medical Center

  • Rural Health Clinic/Center
  • The Dalles, OR
  • NPI 1871833772
  NPD
• Mid-Columbia Medical Center

  • Rural Health Clinic/Center
  • The Dalles, OR
  • NPI 1154351336

  Physician Assistant

  NPD (past)
• Mid-Columbia Medical Center

  • Rural Health Clinic/Center
  • The Dalles, OR
  • NPI 1407887052
  NPD (past)
• Mid-Columbia Medical Center

  • Multi-Specialty Clinic/Center
  • The Dalles, OR
  • NPI 1992094817
  NPD (past)

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Klickitat County Public Hospital District No 1

  • Critical Access Hospital
  • Goldendale, WA
  • NPI 1386689487
  Care Compare affiliation
• Mid-Columbia Medical Center

  • Critical Access Hospital Clinic/Center
  • The Dalles, OR
  • NPI 1306842752
  Care Compare affiliation
• Oregon Health & Science University

  • General Acute Care Hospital
  • Portland, OR
  • NPI 1609824010
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1318377600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1401926400000",
    "number": "1053696971",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "BOX 78534",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "53278",
            "telephone_number": "815-398-9491",
            "fax_number": "815-381-7333"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "324 ROXBURY RD",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611075090",
            "telephone_number": "815-398-9491",
            "fax_number": "815-381-7333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "CARLY",
        "middle_name": "ANNE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-10-12",
        "last_updated": "2014-06-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Radha Iyengar
• J&J Journey Counseling Service PLLC
• Jack W. Lenox
• Jack W. Lenox, LTD
• Cynthia Ann Jack, NP
• Dmeka Jackson
• Jill A Jackson, PT
• Neha Jackson
• Mark Kevin Jacob, M.D.
• Abbey Jacobson, CNM

• Physician Assistant in Rockford, IL
• Providers in Rockford, IL by specialty
• Physician Assistant in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.