Provider Demographics
NPI:1306914296
Name:JACKSON, KATHY JO (MD)
Entity type:Individual
Prefix:DR
First Name:KATHY
Middle Name:JO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1003 PINEHURST BLVD
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-2110
Mailing Address - Country:US
Mailing Address - Phone:269-349-2641
Mailing Address - Fax:269-349-2898
Practice Address - Street 1:117 W PATERSON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-2557
Practice Address - Country:US
Practice Address - Phone:269-349-2641
Practice Address - Fax:269-349-2898
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2022-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI070748208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104509048Medicaid