Jackson Pemberton, MD

Primary specialty

Anatomic Pathology & Clinical Pathology PhysicianTaxonomy code 207ZP0102X

License

25835 Issued in KY

Practice address

1 Medical Village Dr
Edgewood, KY 41017-3403

Phone

(859) 301-2018

Fax

(859) 301-2073

NPI assigned

Sep 23, 2005

Last updated

Sep 20, 2018By the provider in NPPES

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

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

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": "1127433600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1537401600000",
    "number": "1891781969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 636324",
            "city": "CINCINNATI",
            "state": "OH",
            "postal_code": "452636324",
            "telephone_number": "859-301-2018",
            "fax_number": "859-301-2073"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 MEDICAL VILLAGE DR",
            "city": "EDGEWOOD",
            "state": "KY",
            "postal_code": "410173403",
            "telephone_number": "859-301-2018",
            "fax_number": "859-301-2073"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PEMBERTON",
        "first_name": "JACKSON",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-09-23",
        "last_updated": "2018-09-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207ZP0101X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology",
            "state": "KY",
            "license": "25835",
            "primary": false
        },
        {
            "code": "207ZP0102X",
            "taxonomy_group": "",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": "KY",
            "license": "25835",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2463507",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "64258353",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Anatomic Pathology & Clinical Pathology Physician in Edgewood, KY
• Providers in Edgewood, KY by specialty
• Anatomic Pathology & Clinical Pathology Physician in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 20, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.