Active NPI
J. Phillip Jackson, M.D.
- Family Medicine Physician
- Fort Wayne, IN
National Provider Identifier
1881675080
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 01037752A
- Practice address
- 7980 W Jefferson Blvd
Fort Wayne, IN 46804-4170 - Phone
- (260) 436-9454
- Fax
- (260) 436-7836
- NPI assigned
- Nov 7, 2005
- Sex
- Male
- 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 |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 01037752A | IN | Primary |
Addresses
Primary practice location
7980 W Jefferson Blvd
Fort Wayne, IN 46804-4170
Mailing address
3534 Brooklyn Ave
Fort Wayne, IN 46809-1361
Phone (260) 747-6171
Other identifiers 5
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 000000000892 | Other | MPLAN | |
| 1431 | Other | PHYSICIANS HEALTH PLAN | |
| 080121955 | Other | IN | RAILROAD MEDICARE |
| 000000091890 | Other | BLUE CROSS BLUE SHIELD | |
| 100462820 | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Summit Radiology P C | Past | Accepting new patients |
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.
-
- Diagnostic Radiology Physician
- Fort Wayne, IN
- NPI 1073584587
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1131321600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1361491200000",
"number": "1881675080",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3534 BROOKLYN AVE",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468091361",
"telephone_number": "260-747-6171",
"fax_number": "260-478-5125"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7980 W JEFFERSON BLVD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "468044170",
"telephone_number": "260-436-9454",
"fax_number": "260-436-7836"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "J.",
"middle_name": "PHILLIP",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-11-07",
"last_updated": "2013-02-22",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "IN",
"license": "01037752A",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MPLAN",
"identifier": "000000000892",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PHYSICIANS HEALTH PLAN",
"identifier": "1431",
"state": null
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "080121955",
"state": "IN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "000000091890",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100462820",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Wayne, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.