| National Provider Identifier [NPI]: | 1558301168 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | SHANNON |
| Middle Initial Of The Provider | E |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4805 NE GLISAN ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 972132933 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 11 |
| Number Of Services | 238 |
| Number Of Medicare Beneficiaries | 214 |
| Total Submitted Charge Amount | 139648 |
| Total Medicare Allowed Amount | 44192.48 |
| Total Medicare Payment Amount | 33507.41 |
| Total Medicare Standardized Payment Amount | 34098.87 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 11 |
| Number Of Medical Services | 238 |
| Number Of Medicare Beneficiaries With Medical Services | 214 |
| Total Medical Submitted Charge Amount | 139648 |
| Total Medical Medicare Allowed Amount | 44192.48 |
| Total Medical Medicare Payment Amount | 33507.41 |
| Total Medical Medicare Standardized Payment Amount | 34098.87 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 58 |
| Number Of Beneficiaries Age 65 to 74 | 50 |
| Number Of Beneficiaries Age 75 to 84 | 55 |
| Number Of Beneficiaries Age Greater 84 | 51 |
| Number Of Female Beneficiaries | 113 |
| Number Of Male Beneficiaries | 101 |
| Number Of Non Hispanic White Beneficiaries | 183 |
| Number Of Black or African American Beneficiaries | 12 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 125 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 89 |
| Percent Of With Atrial Fibrillation | 29 |
| Percent Of With Alzheimers Disease or Dementia | 28 |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 35 |
| Percent Of With Chronic Kidney Disease | 50 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 41 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 40 |
| Percent Of With Osteoporosis | 14 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 8 |
| Percent Of With Stroke | 13 |
| Average HCC Risk Score Of Beneficiaries | 2.0882 |