Provider Demographics
NPI:1316938517
Name:JACKSON, KEVIN LEE (MD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2430 VILLAGE PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-2378
Mailing Address - Country:US
Mailing Address - Phone:334-821-6300
Mailing Address - Fax:334-821-1849
Practice Address - Street 1:2430 VILLAGE PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-2378
Practice Address - Country:US
Practice Address - Phone:334-821-6300
Practice Address - Fax:334-821-1849
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6757207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000011573Medicaid
AL000011573Medicaid
AL000011573Medicaid