| National Provider Identifier [NPI]: | 1669433546 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | JOHN |
| Middle Initial Of The Provider | C |
| Credentials Of The Provider | |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 410 E CHEROKEE ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | WAGONER |
| Zip Code Of The Provider | 744674708 |
| State Code Of The Provider | OK |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | General Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 43 |
| Number Of Services | 2626 |
| Number Of Medicare Beneficiaries | 270 |
| Total Submitted Charge Amount | 211814 |
| Total Medicare Allowed Amount | 157516.86 |
| Total Medicare Payment Amount | 109195.71 |
| Total Medicare Standardized Payment Amount | 118891.94 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 97 |
| Number Of Medicare Beneficiaries With Drug Services | 95 |
| Total Drug Submitted ChargeAmount | 1455 |
| Total Drug Medicare AllowedAmount | 1422.08 |
| Total Drug Medicare PaymentAmount | 1392.93 |
| Total Drug Medicare Standardized Payment Amount | 1392.93 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 40 |
| Number Of Medical Services | 2529 |
| Number Of Medicare Beneficiaries With Medical Services | 270 |
| Total Medical Submitted Charge Amount | 210359 |
| Total Medical Medicare Allowed Amount | 156094.78 |
| Total Medical Medicare Payment Amount | 107802.78 |
| Total Medical Medicare Standardized Payment Amount | 117499.01 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 64 |
| Number Of Beneficiaries Age 65 to 74 | 119 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 35 |
| Number Of Female Beneficiaries | 168 |
| Number Of Male Beneficiaries | 102 |
| Number Of Non Hispanic White Beneficiaries | 236 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 22 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 192 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 78 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 17 |
| Percent Of With Chronic Kidney Disease | 9 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 39 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 63 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9482 |