Keith A Jackson, MD

Primary specialty

Otolaryngology PhysicianTaxonomy code 207Y00000X

License

8547 Issued in NV

Practice address

5405 Oberlin Dr FL 2
San Diego, CA 92121-1700

Phone

(858) 909-0770

Fax

(858) 909-0880

NPI assigned

Feb 10, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 3

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles (5 of 6)

Locations

Networks

• BSC 65 PLUS INDIVIDUAL MAPD

Interoperability endpoints

• Direct secure messaging: kjackson81142@scrippshlth.medalliesdirect.net

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.

• Emergency and Acute Care Medical Corporation

  • Emergency Medicine Physician
  • San Diego, CA
  • NPI 1437103942

  CA, Single Specialty

  Medicare reassignment NPD
• Ritvik Mehta, MD Apc

  • Otolaryngology Physician
  • Carlsbad, CA
  • NPI 1538302997

  CA, Single Specialty

  Medicare reassignment NPD
• Scripps Health

  • General Acute Care Hospital
  • San Diego, CA
  • NPI 1487928891
  NPD
• Carlos F Jimenez, MD

  • Otolaryngology Physician
  • Chula Vista, CA
  • NPI 1104914696

  Single Specialty

  NPD (past)
• Kiersten L Riedler MD Corp

  • Medical Specialty Clinic/Center
  • La Jolla, CA
  • NPI 1497346993

  Single Specialty

  NPD (past)

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

{
    "created_epoch": "1139529600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706140800000",
    "number": "1124091970",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 500877",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921500877",
            "telephone_number": "858-279-4221",
            "fax_number": "858-279-4223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5405 OBERLIN DR FL 2",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921211700",
            "telephone_number": "858-909-0770",
            "fax_number": "858-909-0880"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KEITH",
        "middle_name": "A",
        "credential": "MD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-02-10",
        "last_updated": "2024-01-25",
        "certification_date": "2024-01-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Otolaryngology",
            "state": "CA",
            "license": "G58187",
            "primary": false
        },
        {
            "code": "207YX0901X",
            "taxonomy_group": "",
            "desc": "Otolaryngology, Otology & Neurotology",
            "state": "NV",
            "license": "8547",
            "primary": false
        },
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "NV",
            "license": "8547",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "002018083",
            "state": "NV"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "keithjackson@jacke.allscriptsdirect.net",
            "affiliation": "N",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "8010 Frost St",
            "address_2": "STE 503",
            "city": "San Diego",
            "state": "CA",
            "country_code": "US",
            "postal_code": "921232778",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Jimmie Lee Jackson Jr.
• Joi Jackson
• Julia Jackson
• Kaila Rae Jackson
• Kamri Jackson
• Keri Jackson, KERI JACKSON
• Keturah Renee Jackson
• La Tasha Jackson
• Madeleine E. Jackson, MD
• Megan Ann Jackson

• All providers in San Diego, CA
• Otolaryngology Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2024; 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.

Verify at the official NPI Registry.