Individual
EDWIN J JACKSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
112 HOSPITAL LN STE 303, DANVILLE, IN 46122
(317) 718-4000
(317) 718-4005
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
02005444A
IN
207R00000X
Internal Medicine Physician
34. 010939
OH
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
Primary
02005444A
IN
207RP1001X
Pulmonary Disease Physician
02005444A
IN
207RP1001X
Pulmonary Disease Physician
34.010939
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001612224
ANTHEM PTAN
IN
05
—
0093373
—
OH
Enumeration date
03/15/2010
Last updated
03/11/2025
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