| National Provider Identifier [NPI]: | 1154376077 |
| Last Name Of The Provider | JACKMAN |
| First Name Of The Provider | VICKI |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | APRN |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4624 HOLLADAY BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841175206 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 41 |
| Number Of Services | 256 |
| Number Of Medicare Beneficiaries | 89 |
| Total Submitted Charge Amount | 14799 |
| Total Medicare Allowed Amount | 8440.07 |
| Total Medicare Payment Amount | 5736.29 |
| Total Medicare Standardized Payment Amount | 7240.65 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 21 |
| Number Of Medicare Beneficiaries With Drug Services | 17 |
| Total Drug Submitted ChargeAmount | 530 |
| Total Drug Medicare AllowedAmount | 162.73 |
| Total Drug Medicare PaymentAmount | 157.8 |
| Total Drug Medicare Standardized Payment Amount | 157.8 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 34 |
| Number Of Medical Services | 235 |
| Number Of Medicare Beneficiaries With Medical Services | 88 |
| Total Medical Submitted Charge Amount | 14269 |
| Total Medical Medicare Allowed Amount | 8277.34 |
| Total Medical Medicare Payment Amount | 5578.49 |
| Total Medical Medicare Standardized Payment Amount | 7082.85 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 30 |
| Number Of Beneficiaries Age 75 to 84 | 35 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 59 |
| Number Of Male Beneficiaries | 30 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 17 |
| Percent Of With Hyperlipidemia | 29 |
| Percent Of With Hypertension | 48 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.7627 |