| National Provider Identifier [NPI]: | 1164760500 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | KRISTEN |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | PH.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 480 MEDICAL CENTER DR |
| Street Address 2 Of The Provider | DODD HALL 2145 |
| City Of The Provider | COLUMBUS |
| Zip Code Of The Provider | 432101229 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Clinical Psychologist |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 7 |
| Number Of Services | 118 |
| Number Of Medicare Beneficiaries | 88 |
| Total Submitted Charge Amount | 18975 |
| Total Medicare Allowed Amount | 13632.26 |
| Total Medicare Payment Amount | 10687.27 |
| Total Medicare Standardized Payment Amount | 10702.35 |
| 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 | 7 |
| Number Of Medical Services | 118 |
| Number Of Medicare Beneficiaries With Medical Services | 88 |
| Total Medical Submitted Charge Amount | 18975 |
| Total Medical Medicare Allowed Amount | 13632.26 |
| Total Medical Medicare Payment Amount | 10687.27 |
| Total Medical Medicare Standardized Payment Amount | 10702.35 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 38 |
| Number Of Male Beneficiaries | 50 |
| Number Of Non Hispanic White Beneficiaries | 77 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 65 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 23 |
| Percent Of With Atrial Fibrillation | 17 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 16 |
| Percent Of With Heart Failure | 30 |
| Percent Of With Chronic Kidney Disease | 52 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 28 |
| Percent Of With Depression | 63 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 65 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 47 |
| Percent Of With Osteoporosis | 19 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 68 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 13 |
| Percent Of With Stroke | 20 |
| Average HCC Risk Score Of Beneficiaries | 1.9735 |