Provider Demographics
NPI:1538361118
Name:H.S. JACKSON JR. PSC
Entity type:Organization
Organization Name:H.S. JACKSON JR. PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERSCHEL
Authorized Official - Middle Name:SWAN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:270-753-9240
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:SUITE 107E
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:270-753-9240
Mailing Address - Fax:270-767-3629
Practice Address - Street 1:300 S 8TH ST
Practice Address - Street 2:SUITE 107E
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2400
Practice Address - Country:US
Practice Address - Phone:270-753-9240
Practice Address - Fax:270-767-3629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5519P363LF0000X
KY15974208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCL3162Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP
KY7720Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER