Provider Demographics
NPI:1427829548
Name:JACKSON, KEVIN ANTHONY
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANTHONY
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 1:2470 CONSTELLATION DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-4944
Mailing Address - Country:US
Mailing Address - Phone:310-484-8432
Mailing Address - Fax:
Practice Address - Street 1:2470 CONSTELLATION DR UNIT 103
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-4944
Practice Address - Country:US
Practice Address - Phone:310-484-8432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD08566611172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty