Provider Demographics
NPI:1073754065
Name:JACKSON, WILLIE MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIE
Middle Name:MAE
Last Name:JACKSON
Suffix:
Gender:F
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 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-417-7980
Mailing Address - Fax:270-417-7989
Practice Address - Street 1:2211 MAYFAIR DR
Practice Address - Street 2:SUITE 409
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-4568
Practice Address - Country:US
Practice Address - Phone:270-417-7980
Practice Address - Fax:270-417-7989
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY464002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100137210Medicaid
KY7100137210Medicaid
KYK039243Medicare PIN