| National Provider Identifier [NPI]: | 1740294883 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | EDWIN |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4010 CENTRAL AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | ST PETERSBURG |
| Zip Code Of The Provider | 337111239 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Psychiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 4 |
| Number Of Services | 477 |
| Number Of Medicare Beneficiaries | 194 |
| Total Submitted Charge Amount | 43700 |
| Total Medicare Allowed Amount | 34934.41 |
| Total Medicare Payment Amount | 23341.43 |
| Total Medicare Standardized Payment Amount | 23409.56 |
| 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 | 477 |
| Number Of Medicare Beneficiaries With Medical Services | 194 |
| Total Medical Submitted Charge Amount | 43700 |
| Total Medical Medicare Allowed Amount | 34934.41 |
| Total Medical Medicare Payment Amount | 23341.43 |
| Total Medical Medicare Standardized Payment Amount | 23409.56 |
| Average Age Of Beneficiaries | 51 |
| Number Of Beneficiaries Age Less65 | 168 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 99 |
| Number Of Male Beneficiaries | 95 |
| Number Of Non Hispanic White Beneficiaries | 137 |
| Number Of Black or African American Beneficiaries | 40 |
| 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 | 29 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 165 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 11 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 19 |
| Percent Of With Depression | 56 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 43 |
| Percent Of With Ischemic Heart Disease | 16 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 20 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 49 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.221 |