Provider Demographics
NPI:1215971379
Name:JACKSON, KATHY M (DO)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63702-0111
Mailing Address - Country:US
Mailing Address - Phone:423-562-1705
Mailing Address - Fax:
Practice Address - Street 1:502 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3400
Practice Address - Country:US
Practice Address - Phone:423-562-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOH78941Medicare UPIN
TN441877Medicare ID - Type UnspecifiedMEDICARE