Basic Information
| Provider Information | |||||||||
| NPI: | 1972827335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 HOSPITAL LN STE 303 | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177184000 | ||||||||
| FaxNumber: | 3177184005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2010 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34. 010939 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 34.010939 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 02005444A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 02005444A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0093373 | 05 | OH | MEDICAID |