William Jackson, M.D.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

M-14093 Issued in ID

Practice address

1441 NE 10TH Ave
Payette, ID 83661-5420

Phone

(208) 642-9376

Fax

(208) 642-9279

NPI assigned

Sep 11, 2012

Sex

Male

Sole proprietor

No

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.

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Medicare fee-for-service enrollment

Enrolled in UT

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.

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Apr 12, 2019.

{
    "created_epoch": "1347321600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1555027200000",
    "number": "1740530302",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1441 NE 10TH AVE",
            "city": "PAYETTE",
            "state": "ID",
            "postal_code": "836615420",
            "telephone_number": "208-642-9376"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1441 NE 10TH AVE",
            "city": "PAYETTE",
            "state": "ID",
            "postal_code": "836615420",
            "telephone_number": "208-642-9376",
            "fax_number": "208-642-9279"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2327 SW 4th Ave",
            "address_purpose": "LOCATION",
            "city": "Ontario",
            "state": "OR",
            "postal_code": "979141851",
            "country_code": "US",
            "telephone_number": "541-889-2340",
            "fax_number": "541-889-2593",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "WILLIAM",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-09-11",
        "last_updated": "2019-04-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OR",
            "license": "MD187049",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M-14093",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF IDAHO MEDICAL LICENSE",
            "identifier": "M-14093",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE OF OREGON, MEDICAL LICENSE",
            "identifier": "MD187049",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Payette, ID
• Family Medicine Physician in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 12, 2019; 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.