Jacob Stafford Edmisson, MD

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

License

11023782A Issued in IN

Practice address

535 Barnhill Dr
Indianapolis, IN 46202-5116

Phone

(317) 948-6942

NPI assigned

Jun 14, 2021

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

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

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

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

{
    "created_epoch": "1623628800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1718668800000",
    "number": "1609444967",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "535 BARNHILL DR",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462025116",
            "telephone_number": "317-948-6942"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "535 BARNHILL DR",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462025116",
            "telephone_number": "317-948-6942"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "EDMISSON",
        "first_name": "JACOB",
        "middle_name": "STAFFORD",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-06-14",
        "last_updated": "2024-06-18",
        "certification_date": "2024-06-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "IN",
            "license": "11023782A",
            "primary": true
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "MO",
            "license": "2021021803",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kelly Jean Edge, CGC
• Leslie D Edgecomb, O.T.
• Karen Sue Edgerson, R.PH., PH.D.
• Randall Kirk Edgerson, PHARM D
• Tyler Edlin, PHARMD
• Sandra Marie Edmond, MS,RD,CD
• April Edmonds, COTA
• Brian T Edmonds, LCSW
• Danneika Edmondson
• James W Edmondson, M.D.

• Student in an Organized Health Care Education/Training Program in Indianapolis, IN
• Providers in Indianapolis, IN by specialty
• Student in an Organized Health Care Education/Training Program in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 18, 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.