Provider Demographics
NPI:1033201983
Name:JACKSON, ROBERT VINCENT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:VINCENT
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 1:1001 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64113-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8901 W 74TH ST
Practice Address - Street 2:SUITE 10
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-2204
Practice Address - Country:US
Practice Address - Phone:913-362-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-18613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics