Active NPI
Joann Michelle Jackson, PSY.D.
- Psychologist
- South Bend, IN
National Provider Identifier
1194739904
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 20040982A
- Practice address
- 403 E Madison St
South Bend, IN 46617-2322 - Phone
- (574) 533-1234
- Fax
- (574) 537-2652
- NPI assigned
- Jul 28, 2006
- Sex
- Female
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Psychologist | 103T00000X | 20040982A | IN | Primary |
Addresses
Primary practice location
403 E Madison St
South Bend, IN 46617-2322
Mailing address
330 Lakeview Dr
Goshen, IN 46528-9365
Phone (574) 533-1234
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200200700A | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
Enrollment records 1
Care Compare profile
Medicare Care Compare- Specialty
- Clinical Psychologist
- Education
- Other, 1993
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Telehealth
- Offers telehealth services
- Group practices
Practice addresses (Care Compare)
415 E Madison St
South Bend, IN 46617-2322
Phone (574) 533-1234
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 20040982A | IN | MD | Psychologist |
Organizations & group practices 1
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.
-
- Mental Health Clinic/Center (Including Community Mental Health Center)
- Elkhart, IN
- NPI 1598847212
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154044800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1285545600000",
"number": "1194739904",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "330 LAKEVIEW DR",
"city": "GOSHEN",
"state": "IN",
"postal_code": "465289365",
"telephone_number": "574-533-1234",
"fax_number": "574-537-2652"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "403 E MADISON ST",
"city": "SOUTH BEND",
"state": "IN",
"postal_code": "466172322",
"telephone_number": "574-533-1234",
"fax_number": "574-537-2652"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "JOANN",
"middle_name": "MICHELLE",
"credential": "PSY.D.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-07-28",
"last_updated": "2010-09-27",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "IN",
"license": "20040982A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200200700A",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Bend, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 27, 2010; 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.