Kevin W Jackson, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

50.004297RX Issued in OH

Practice address

801 Pro Dr Ste D1
Celina, OH 45822-3307

Phone

(419) 586-6489

Fax

(419) 586-8509

NPI assigned

Mar 12, 2015

Sex

Male

Sole proprietor

No

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

Specialties & licenses 1

Addresses

Other identifiers 1

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in OH

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2014

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Joint Township District Memorial HospitalGroup PAC ID 3870491590, 39 clinicians

JTDM Family Practice LLCGroup PAC ID 2163415837, 48 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• Grand Lake Health System Hospital, Saint Marys, OH, CCN 360032
• Mercer County Joint Township Community Hospital Hospital, Coldwater, OH, CCN 360058

Merit-based Incentive Payment System (MIPS)

Final score

85.44 of 100Reported as group

Quality

78

Promoting interoperability

96

Improvement activities

40

Cost

76.79

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Interoperability endpoints

• Direct secure messaging: kevinjackson@glhs.allscriptsdirect.net

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.

• JTDM Family Practice LLC

  • Family Medicine Physician
  • Saint Marys, OH
  • NPI 1184652539

  Physician Assistant

  Medicare reassignment Care Compare group NPD
• Joint Township District Memorial Hospital

  • General Acute Care Hospital
  • Saint Marys, OH
  • NPI 1639133002
  Medicare reassignment Care Compare group
• Lima Memorial Joint Operating Company

  dba Lima Memorial Health System

  • General Acute Care Hospital
  • Lima, OH
  • NPI 1336144732
  NPD (past)

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

• Joint Township District Memorial Hospital

  • General Acute Care Hospital
  • Saint Marys, OH
  • NPI 1639133002
  Care Compare affiliation
• Mercer County Joint Township Community Hospital

  dba Mercer Health

  • General Acute Care Hospital
  • Coldwater, OH
  • NPI 1497784144
  Care Compare affiliation

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

{
    "created_epoch": "1426118400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1712016000000",
    "number": "1871986083",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1140 S KNOXVILLE AVE STE D",
            "city": "SAINT MARYS",
            "state": "OH",
            "postal_code": "458852609",
            "telephone_number": "419-300-1129"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "801 PRO DR STE D1",
            "city": "CELINA",
            "state": "OH",
            "postal_code": "458223307",
            "telephone_number": "419-586-6489",
            "fax_number": "419-586-8509"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "812 Redskin Trl",
            "address_purpose": "LOCATION",
            "city": "Wapakoneta",
            "state": "OH",
            "postal_code": "458958545",
            "country_code": "US",
            "telephone_number": "419-586-6489",
            "fax_number": "419-586-8509",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KEVIN",
        "middle_name": "W",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2015-03-12",
        "last_updated": "2024-04-02",
        "certification_date": "2024-04-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OH",
            "license": "50.004297RX",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0121263",
            "state": "OH"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kevinjackson@glhs.allscriptsdirect.net",
            "affiliation": "Y",
            "affiliationName": "JTDM Family Practice LLC",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "801 Pro Dr Ste D1",
            "city": "Celina",
            "state": "OH",
            "country_code": "US",
            "postal_code": "458223307",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kevinjackson@glhs.allscriptsdirect.net",
            "affiliation": "Y",
            "affiliationName": "JTDM Family Practice LLC",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "address_1": "812 Redskin Trl",
            "city": "Wapakoneta",
            "state": "OH",
            "country_code": "US",
            "postal_code": "458958545",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Jeffrey Hudnall
• Ellen J Hunter, AU.D.
• Elizabeth Ann Huwer, COTA/L
• Jason John Iannantuono, CDCA
• Ashlie Ibarra
• Ellie Johnson, COTA
• Leslie Johnson, PA
• Jon T. Romer, O.D. & Associates, Inc.
• Daniel Jones
• JTDM Family Practice LLC

• Physician Assistant in Celina, OH
• Providers in Celina, OH by specialty
• Physician Assistant in Ohio

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 2, 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.
• 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.

Verify at the official NPI Registry.