Peter C. Jackson, PSYD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

1805-057 Issued in WI

Practice address

700 Ray O Vac Dr
Suite 220
Madison, WI 53711-2479

Phone

(608) 276-9191

Fax

(608) 276-9144

NPI assigned

Dec 27, 2006

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective May 21, 2024 through May 21, 2028

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

State licenses

Practice roles

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.

• Geriatric Psychiatric Services PLLC

  • Clinical Psychologist
  • Indianapolis, IN
  • NPI 1073753323
  NPD (past)

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

{
    "created_epoch": "1167177600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1548115200000",
    "number": "1942365994",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3330 UNIVERSITY AVE",
            "address_2": "STE 312",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537052167",
            "telephone_number": "608-276-9191",
            "fax_number": "608-276-9144"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "700 RAY O VAC DR",
            "address_2": "SUITE 220",
            "city": "MADISON",
            "state": "WI",
            "postal_code": "537112479",
            "telephone_number": "608-276-9191",
            "fax_number": "608-276-9144"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "PETER",
        "middle_name": "C.",
        "credential": "PSYD",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-12-27",
        "last_updated": "2019-01-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "WI",
            "license": "1805-057",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "39105300",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Lisa Jackson
• Lisa Jackson, MS, MFT
• Lucy Jackson, M.S.W.
• Mark K Jackson, DDS
• Nicole C Jackson, MS LMFT
• Sadie Schadewald Jackson, MD
• Sally A Jackson, LCSW
• Sara Ann Jackson, N.P.
• Tyeshia Jackson
• Alexis Danielle Jacob, M.D.

• Clinical Psychologist in Madison, WI
• Providers in Madison, WI by specialty
• Clinical Psychologist in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.