NPIMap

Individual provider Active NPI

Brian Gene Jackson, PAC

  • Physician Assistant
  • La Jara, CO
National Provider Identifier
1245261064
Registry record updated May 6, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
843 Issued in CO
Practice address
509 Main Street
La Jara, CO 81140
Phone
(719) 376-2308
Fax
(719) 376-2395
NPI assigned
Jul 6, 2006
Last updated
May 6, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 6, 2021

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 843 CO Primary

Addresses

Primary practice location

509 Main Street
La Jara, CO 81140

Mailing address

19021 US Highway 285
La Jara, CO 81140-9410
Phone (719) 376-2308

Other identifiers 1

IdentifierTypeStateIssuer
07008436MedicaidCO

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address amc.bjackson@direct.slvrmc.org Direct

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20110425000598 CO Practitioner - Physician Assistant 5890970461 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
University of Colorado School of Medicine, Denver, 1993
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

106 Blanca Ave
Alamosa, CO 81101-2340
Phone (719) 589-2511

310 County Rd
Suite 14
Del Norte, CO 81132-8758
Phone (719) 657-2510

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
843COMDAcupuncturist

Practice roles

OrganizationSpecialtyStatusNew patients
Lutheran Hospital Association of the San Luis Valley CurrentSince Dec 27, 2017 Accepting new patients
Lutheran Hospital Association of the San Luis Valley CurrentSince Dec 27, 2017 Accepting new patients
Lutheran Hospital Association of the San Luis Valley Physician Assistant CurrentSince Dec 27, 2017 Accepting new patients
Lutheran Hospital Association of the San Luis Valley Past Accepting new patients

Locations

2115 Stuart Ave
Alamosa, CO 81101
Phone (719) 589-3000

310 County Road 14
Del Norte, CO 81132
Phone (719) 657-2510

19021 US Highway 285
La Jara, CO 81140
Phone (719) 274-5121

Interoperability endpoints

  • Direct secure messaging: amc.bjackson@direct.slvrmc.org

Organizations & group practices 4

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 3

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": "1152144000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620259200000",
    "number": "1245261064",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19021 US HIGHWAY 285",
            "city": "LA JARA",
            "state": "CO",
            "postal_code": "811409410",
            "telephone_number": "719-376-2308",
            "fax_number": "719-274-6065"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "509 MAIN STREET",
            "city": "LA JARA",
            "state": "CO",
            "postal_code": "81140",
            "telephone_number": "719-376-2308",
            "fax_number": "719-376-2395"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "BRIAN",
        "middle_name": "GENE",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-06",
        "last_updated": "2021-05-06",
        "certification_date": "2021-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CO",
            "license": "843",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07008436",
            "state": "CO"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "amc.bjackson@direct.slvrmc.org",
            "affiliation": "N",
            "endpointDescription": "San Luis Valley Health PCP Brian Jackson",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCD",
            "address_1": "509 Main Street",
            "city": "La Jara",
            "state": "CO",
            "country_code": "US",
            "postal_code": "81140",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in La Jara, CO

Sources for this page

Verify at the official NPI Registry.