Provider Demographics
NPI:1093853350
Name:JEFFERSON COUNTY PULMONARY & SLEEP MEDICINE
Entity Type:Organization
Organization Name:JEFFERSON COUNTY PULMONARY & SLEEP MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:636-937-3121
Mailing Address - Street 1:807 CRAIG FOREST LN
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-5567
Mailing Address - Country:US
Mailing Address - Phone:636-937-3121
Mailing Address - Fax:636-937-4423
Practice Address - Street 1:1390 US HIGHWAY 61 STE 2300
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4121
Practice Address - Country:US
Practice Address - Phone:636-937-3121
Practice Address - Fax:636-937-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9F09207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12422Medicare UPIN