Provider Demographics
NPI:1205815982
Name:JACKSON, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA
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 432
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-0432
Mailing Address - Country:US
Mailing Address - Phone:606-430-2206
Mailing Address - Fax:606-218-7506
Practice Address - Street 1:911 BYPASS RD BLDG A
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1689
Practice Address - Country:US
Practice Address - Phone:606-430-2206
Practice Address - Fax:606-218-7506
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002903Medicaid
P00164787OtherRAILROAD
KYP00363176OtherRAILROAD MEDICARE
KY000000521209OtherBCBS
P00164787OtherRAILROAD
KY0931024Medicare PIN
KY3403722Medicare PIN