Provider Demographics
NPI:1073525861
Name:MAXEY, JACKIE D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:D
Last Name:MAXEY
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 1676
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-1676
Mailing Address - Country:US
Mailing Address - Phone:606-878-9611
Mailing Address - Fax:606-862-7565
Practice Address - Street 1:102 PROFESSIONAL DR
Practice Address - Street 2:SUITE #2
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8857
Practice Address - Country:US
Practice Address - Phone:606-878-9611
Practice Address - Fax:606-862-7565
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64009913Medicaid
KY0747901Medicare ID - Type Unspecified
KY64009913Medicaid