Provider Demographics
NPI:1063583268
Name:JACKSON, JAMES W JR (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:120 EXECUTIVE PARK
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-855-7200
Practice Address - Fax:502-855-7201
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062749A207LP2900X
KY41100208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY719905OtherWELLCARE OF KY PROVIDER ID
002903176OtherUNITED HEALTHCARE PROVIDER ID NUMBER
9121168OtherAETNA PIN
IN200872860Medicaid
000000858929OtherANTHEM PIN
KY7100003940Medicaid
CS1434500725OtherCARESOURCE ID
KY135386KYIPOtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER