NPIMap

Individual provider Active NPI

Kenneth Jason Jackson, MD

  • Family Medicine Physician
  • Lebanon, NH
National Provider Identifier
1174083810
Registry record updated Aug 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
22456 Issued in NH
Practice address
18 Old Etna Rd
Lebanon, NH 03766-1937
Phone
(603) 650-5000
NPI assigned
Mar 20, 2019
Last updated
Aug 19, 2022By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 19, 2022

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 22456 NH Primary

Addresses

Primary practice location

18 Old Etna Rd
Lebanon, NH 03766-1937

Mailing address

18 Old Etna Rd
Lebanon, NH 03766-1937

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NH, MA2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20221012000270 NH Practitioner - Family Practice 1052787389 Reassigns benefits to 2 organizations
I20240717000516 MA Practitioner - Family Practice 1052787389 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Howard University College of Medicine, 2019
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

525 Long Pond Dr
Harwich, MA 02645-1227
Phone (508) 430-3330

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
76.23 of 100Reported as group
Quality
56.78
Promoting interoperability
100
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
79.66 of 100Reported as apm
Quality
53.51
Promoting interoperability
100
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
79.66 of 100Reported as apm
Quality
53.51
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
22456NHMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Dartmouth-Hitchcock Clinic CurrentSince Oct 3, 2022 Accepting new patients
Physicians of Cape Cod Hospital CurrentSince Sep 1, 2024 Accepting new patients
Medical Affiliates of Cape Cod, Inc. Family Medicine CurrentSince Sep 1, 2024 Accepting new patients
Mary Hitchcock Memorial Hospital CurrentSince Oct 3, 2022 Accepting new patients
Medical Affiliates of Cape Cod, Inc. CurrentSince Sep 1, 2024 Accepting new patients
Dartmouth-Hitchcock Clinic CurrentSince Oct 3, 2022 Accepting new patients
Mary Hitchcock Memorial Hospital CurrentSince Oct 3, 2022 Accepting new patients

Locations

525 Long Pond Dr
Harwich, MA 02645
Phone (508) 430-3311

525 Long Pond Dr
Ste 1
Harwich, MA 02645

27 Park St
Hyannis, MA 02601
Phone (508) 775-5011

297 North St
Ste 221
Hyannis, MA 02601
Phone (508) 862-5032

1 Medical Dr
Lebanon, NH 03756
Phone (603) 650-5922

18 Old Etna Rd
Lebanon, NH 03766
Phone (603) 650-3100

Organizations & group practices 7

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

Hospital & facility affiliations 9

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

NPI Registry JSON

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

{
    "created_epoch": "1553040000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1660867200000",
    "number": "1174083810",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18 OLD ETNA RD",
            "city": "LEBANON",
            "state": "NH",
            "postal_code": "037661937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18 OLD ETNA RD",
            "city": "LEBANON",
            "state": "NH",
            "postal_code": "037661937",
            "telephone_number": "603-650-5000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KENNETH",
        "middle_name": "JASON",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-03-20",
        "last_updated": "2022-08-19",
        "certification_date": "2022-08-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NH",
            "license": "22456",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, NH

Sources for this page

Verify at the official NPI Registry.