Provider Demographics
NPI:1235235136
Name:DR JERRY S JACKSON & ASSOCIATES P A
Entity Type:Organization
Organization Name:DR JERRY S JACKSON & ASSOCIATES P A
Other - Org Name:DR JERRY S JACKSON AND ASSOCIATES P A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:913-682-4335
Mailing Address - Street 1:113 DELAWARE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-2822
Mailing Address - Country:US
Mailing Address - Phone:913-682-4335
Mailing Address - Fax:913-682-2985
Practice Address - Street 1:113 DELAWARE ST
Practice Address - Street 2:SUITE D
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-2822
Practice Address - Country:US
Practice Address - Phone:913-682-4335
Practice Address - Fax:913-682-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS145261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST77063Medicare UPIN
KS006796Medicare ID - Type UnspecifiedCORPORATION