Active NPI
Travis Wiley Jackson, MD
- Dermatology Physician
- Saint Louis, MO
National Provider Identifier
1093657439
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- 2026021643
- Practice address
- 621 S New Ballas Rd Ste 3019B
Saint Louis, MO 63141-8267 - Phone
- (314) 509-5305
- Fax
- (314) 251-4454
- NPI assigned
- Apr 6, 2026
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | 2026021643 | MO | Primary |
Addresses
Primary practice location
621 S New Ballas Rd Ste 3019B
Saint Louis, MO 63141-8267
Mailing address
621 S New Ballas Rd Ste 3019B
Saint Louis, MO 63141-8267
Phone (314) 509-5305
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260612003692 | MO | Order and Referring Only - Dermatology | 0749752418 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2026021643 | MO | MD | Dermatology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1775433600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1779840000000",
"number": "1093657439",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "621 S NEW BALLAS RD STE 3019B",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631418267",
"telephone_number": "314-509-5305",
"fax_number": "314-251-4454"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "621 S NEW BALLAS RD STE 3019B",
"city": "SAINT LOUIS",
"state": "MO",
"postal_code": "631418267",
"telephone_number": "314-509-5305",
"fax_number": "314-251-4454"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "TRAVIS",
"middle_name": "WILEY",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2026-04-06",
"last_updated": "2026-05-27",
"certification_date": "2026-05-27",
"status": "A"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dermatology",
"state": "MO",
"license": "2026021643",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Saint Louis, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 27, 2026; 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.