| National Provider Identifier [NPI]: | 1255679940 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | NICOLE |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | CNP, ACNP-BC |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3535 SOUTHERN BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | KETTERING |
| Zip Code Of The Provider | 454291221 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 568 |
| Number Of Medicare Beneficiaries | 96 |
| Total Submitted Charge Amount | 78627 |
| Total Medicare Allowed Amount | 38893.43 |
| Total Medicare Payment Amount | 30446.74 |
| Total Medicare Standardized Payment Amount | 36338.46 |
| 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 | 12 |
| Number Of Medical Services | 568 |
| Number Of Medicare Beneficiaries With Medical Services | 96 |
| Total Medical Submitted Charge Amount | 78627 |
| Total Medical Medicare Allowed Amount | 38893.43 |
| Total Medical Medicare Payment Amount | 30446.74 |
| Total Medical Medicare Standardized Payment Amount | 36338.46 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 41 |
| Number Of Beneficiaries Age 65 to 74 | 28 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 49 |
| Number Of Male Beneficiaries | 47 |
| Number Of Non Hispanic White Beneficiaries | 61 |
| Number Of Black or African American Beneficiaries | 35 |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 45 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 51 |
| Percent Of With Atrial Fibrillation | 23 |
| Percent Of With Alzheimers Disease or Dementia | 24 |
| Percent Of With Asthma | 20 |
| Percent Of With Cancer | 14 |
| Percent Of With Heart Failure | 49 |
| Percent Of With Chronic Kidney Disease | 73 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 51 |
| Percent Of With Diabetes | 59 |
| Percent Of With Hyperlipidemia | 68 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 52 |
| Percent Of With Osteoporosis | 18 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 53 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 19 |
| Percent Of With Stroke | 21 |
| Average HCC Risk Score Of Beneficiaries | 3.3835 |