Provider Demographics
NPI:1215501358
Name:JACKSON, KEVIN GABRIEL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GABRIEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6206 COUNTY ROAD 4511
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75752-5778
Mailing Address - Country:US
Mailing Address - Phone:903-603-6863
Mailing Address - Fax:
Practice Address - Street 1:6206 COUNTY ROAD 4511
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75752-5778
Practice Address - Country:US
Practice Address - Phone:903-603-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29219719343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)