Provider Demographics
NPI:1104143072
Name:JACKSON, KEEGAN MARIE (MD)
Entity type:Individual
Prefix:
First Name:KEEGAN
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 CHANNEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-7837
Mailing Address - Country:US
Mailing Address - Phone:907-463-4040
Mailing Address - Fax:
Practice Address - Street 1:3245 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7809
Practice Address - Country:US
Practice Address - Phone:907-463-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54140207Q00000X
AK7867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080021655Medicare Oscar/Certification