Basic Information
| Provider Information | |||||||||
| NPI: | 1477511921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | MORRIS | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 S DUPONT SQ STE C | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 22181 | KY | Y | Allopathic & Osteopathic Physicians | Urology | 208800000X | 01039636A | IN | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 64221815 | 05 | KY | MEDICAID | 201028460 | 05 | IN | MEDICAID | P00314088 | 01 | KY | RAILROAD MEDICARE | OTHER | 00895267 | 01 | KY | RAILROAD MEDICARE | OTHER |