Individual
COURTNEY MARIE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
6507 E STATE BLVD, FORT WAYNE, IN 46815-7026
(260) 486-3300
(260) 485-3600
Mailing address
11109 PARKVIEW PLAZA DR # 117, FORT WAYNE, IN 46845-1701
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01088399A
IN
207Q00000X
Family Medicine Physician
11021251A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
068010931
MEDICARE PTAN
IN
01
—
266430813
MEDICARE PTAN
—
05
—
300041262
—
IN
Enumeration date
06/17/2020
Last updated
02/02/2026
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