NPIMap

Individual provider Active NPI

Larry D Jackson, PA-C

  • Physician Assistant
  • Youngstown, OH
National Provider Identifier
1912928441
Registry record updated Nov 20, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
50-000351 Issued in OH
Practice address
500 Gypsy LN
Youngstown, OH 44504-1315
Phone
(330) 884-1000
NPI assigned
Jul 21, 2006
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Nov 20, 2014

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 50-000351 OH Primary
Personal Emergency Response Attendant 146D00000X 50000351 OH

Addresses

Primary practice location

500 Gypsy LN
Youngstown, OH 44504-1315

Mailing address

16620 Downey Glen TRL
Burton, OH 44021-9319

Other identifiers 1

IdentifierTypeStateIssuer
970029949OtherOHMEDICARE TRAVELERS RR-GA

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
Physician Assistant

State licenses

LicenseStateTypeSpecialty
50000351OHMDPersonal Emergency Response Attendant
50-000351OHMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Lake Hospital System, Inc Past Accepting new patients
University Primary Care Practices Inc Past Accepting new patients
Emergency Professionals of Ohio, Inc. Physician Assistant Past Accepting new patients
Lake Hospital System, Inc Past Accepting new patients
Lake Emergency Services Inc Past Accepting new patients

Organizations & group practices 5

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.

NPI Registry JSON

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

{
    "created_epoch": "1153440000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1416441600000",
    "number": "1912928441",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "16620 DOWNEY GLEN TRL",
            "city": "BURTON",
            "state": "OH",
            "postal_code": "440219319"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "500 GYPSY LN",
            "city": "YOUNGSTOWN",
            "state": "OH",
            "postal_code": "445041315",
            "telephone_number": "330-884-1000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "LARRY",
        "middle_name": "D",
        "credential": "PA-C",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-07-21",
        "last_updated": "2014-11-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OH",
            "license": "50-000351",
            "primary": true
        },
        {
            "code": "146D00000X",
            "taxonomy_group": "",
            "desc": "Personal Emergency Response Attendant",
            "state": "OH",
            "license": "50000351",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE TRAVELERS RR-GA",
            "identifier": "970029949",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Youngstown, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 20, 2014; 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.