Provider Demographics
NPI:1194792796
Name:JACKSON, HERSCHEL S JR (MD)
Entity type:Individual
Prefix:
First Name:HERSCHEL
Middle Name:S
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 1:300 S 8TH ST
Mailing Address - Street 2:SUITE 107#
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 107#
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15974208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY020006711OtherRAILROAD MEDICARE ID
KY64159742Medicaid
KY000000045254OtherANTHEM ID
KY64159742Medicaid
KYA98934Medicare UPIN