Individual
J. PHILLIP JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
7980 W JEFFERSON BLVD, FORT WAYNE, IN 46804-4170
(260) 436-9454
(260) 436-7836
Mailing address
3534 BROOKLYN AVE, FORT WAYNE, IN 46809-1361
(260) 747-6171
(260) 478-5125
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01037752A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000000892
MPLAN
—
01
—
000000091890
BLUE CROSS BLUE SHIELD
—
01
—
080121955
RAILROAD MEDICARE
IN
05
—
100462820
—
IN
01
—
1431
PHYSICIANS HEALTH PLAN
—
Enumeration date
11/07/2005
Last updated
02/22/2013
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