Provider Demographics
NPI:1235624354
Name:HACKWORTH, JEFFREY (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HACKWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 W LINK ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4342
Mailing Address - Country:US
Mailing Address - Phone:909-374-7466
Mailing Address - Fax:
Practice Address - Street 1:315 S OSTEOPATHY AVE
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-6401
Practice Address - Country:US
Practice Address - Phone:660-785-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018022479207Q00000X
MO2019036773208D00000X
TXT8554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice