Basic Information
| Provider Information | |||||||||
| NPI: | 1982654828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | FRANKLIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | HUNTERTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467480670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 MAGNAVOX WAY | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 02001273 | IN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 21371 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 76572 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 02001273A | IN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0426440001 | 01 | IN | DME | OTHER | 100352280 | 05 | IN | MEDICAID | 000000082970 | 01 | IN | ANTHEM BCBS | OTHER | 02001273 | 01 | IN | LICENSE | OTHER |