| National Provider Identifier [NPI]: | 1104034008 |
| Last Name Of The Provider | JACKSON |
| First Name Of The Provider | HEATHER |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2322 LAKEVIEW DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | BEAVERCREEK |
| Zip Code Of The Provider | 454312772 |
| State Code Of The Provider | OH |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 38 |
| Number Of Services | 392 |
| Number Of Medicare Beneficiaries | 127 |
| Total Submitted Charge Amount | 30652 |
| Total Medicare Allowed Amount | 19728.42 |
| Total Medicare Payment Amount | 11945.34 |
| Total Medicare Standardized Payment Amount | 13174 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 11 |
| Number Of Drug Services | 59 |
| Number Of Medicare Beneficiaries With Drug Services | 18 |
| Total Drug Submitted ChargeAmount | 1233 |
| Total Drug Medicare AllowedAmount | 447.23 |
| Total Drug Medicare PaymentAmount | 414.01 |
| Total Drug Medicare Standardized Payment Amount | 414.01 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 27 |
| Number Of Medical Services | 333 |
| Number Of Medicare Beneficiaries With Medical Services | 127 |
| Total Medical Submitted Charge Amount | 29419 |
| Total Medical Medicare Allowed Amount | 19281.19 |
| Total Medical Medicare Payment Amount | 11531.33 |
| Total Medical Medicare Standardized Payment Amount | 12759.99 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 61 |
| Number Of Beneficiaries Age 75 to 84 | 29 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 91 |
| Number Of Male Beneficiaries | 36 |
| Number Of Non Hispanic White Beneficiaries | 116 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | 102 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 25 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 11 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 16 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 20 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 69 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0174 |