Provider Demographics
NPI:1699429324
Name:JACKSON, KENNETH MITCHELL
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MITCHELL
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 1:3131 WEST LOOP S APT 481
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-6136
Mailing Address - Country:US
Mailing Address - Phone:323-898-8918
Mailing Address - Fax:
Practice Address - Street 1:3131 WEST LOOP S APT 481
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-6136
Practice Address - Country:US
Practice Address - Phone:323-898-8918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-10
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program