| National Provider Identifier [NPI]: | 1528055050 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | DOLORES |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1725 ASHLEY CIR |
| Street Address 2 Of The Provider | 209A |
| City Of The Provider | BOWLING GREEN |
| Zip Code Of The Provider | 421043337 |
| State Code Of The Provider | KY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | CRNA |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 4 |
| Number Of Services | 1280 |
| Number Of Medicare Beneficiaries | 918 |
| Total Submitted Charge Amount | 779960 |
| Total Medicare Allowed Amount | 136698.99 |
| Total Medicare Payment Amount | 105538.87 |
| Total Medicare Standardized Payment Amount | 110576.1 |
| 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 | 4 |
| Number Of Medical Services | 1280 |
| Number Of Medicare Beneficiaries With Medical Services | 918 |
| Total Medical Submitted Charge Amount | 779960 |
| Total Medical Medicare Allowed Amount | 136698.99 |
| Total Medical Medicare Payment Amount | 105538.87 |
| Total Medical Medicare Standardized Payment Amount | 110576.1 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 97 |
| Number Of Beneficiaries Age 65 to 74 | 506 |
| Number Of Beneficiaries Age 75 to 84 | 269 |
| Number Of Beneficiaries Age Greater 84 | 46 |
| Number Of Female Beneficiaries | 512 |
| Number Of Male Beneficiaries | 406 |
| Number Of Non Hispanic White Beneficiaries | 880 |
| Number Of Black or African American Beneficiaries | 27 |
| 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 | 717 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 201 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 5 |
| Percent Of With Cancer | 5 |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 54 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 4 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 0.9863 |