Provider Demographics
NPI:1306818968
Name:JACKSON, THOMAS COZATT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:COZATT
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 LINDEN AVE STE 3-4
Mailing Address - Street 2:
Mailing Address - City:HARRODSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40330-1871
Mailing Address - Country:US
Mailing Address - Phone:859-734-4307
Mailing Address - Fax:859-734-4300
Practice Address - Street 1:470 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:HARRODSBURG
Practice Address - State:KY
Practice Address - Zip Code:40330-1871
Practice Address - Country:US
Practice Address - Phone:859-734-4307
Practice Address - Fax:859-734-4300
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64292220Medicaid
KY64292220Medicaid
0606601Medicare ID - Type Unspecified