Provider Demographics
NPI:1023219425
Name:JACKSON PHYSICIAN CORP
Entity Type:Organization
Organization Name:JACKSON PHYSICIAN CORP
Other - Org Name:DBA JACKSON UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-693-0531
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339-0790
Mailing Address - Country:US
Mailing Address - Phone:606-693-0531
Mailing Address - Fax:606-693-0535
Practice Address - Street 1:1550 HIGHWAY 15 S STE 27
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339-8604
Practice Address - Country:US
Practice Address - Phone:606-693-0116
Practice Address - Fax:606-693-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY254922088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9619Medicare ID - Type UnspecifiedMEDICARE GROUP