Provider Demographics
NPI:1316977945
Name:JACKSON, KIRK LEE (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:M
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:PO BOX 870
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35056-0870
Mailing Address - Country:US
Mailing Address - Phone:855-230-8290
Mailing Address - Fax:256-775-6305
Practice Address - Street 1:2506 DANVILLE RD SW
Practice Address - Street 2:SUITE 101
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35603-4232
Practice Address - Country:US
Practice Address - Phone:256-350-6363
Practice Address - Fax:256-350-6855
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18273207R00000X
ALMD18273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1316977945Medicaid
AL110160764OtherRAILROAD MEDICARE
AL51077099OtherBLUE CROSS & BLUE SHIELD
AL77099Medicaid
ALF80724Medicare UPIN
AL110160764OtherRAILROAD MEDICARE
AL77099Medicare ID - Type Unspecified