Provider Demographics
NPI:1477795086
Name:JACKSON PURCHASE PEDIATRICS, PLLC
Entity Type:Organization
Organization Name:JACKSON PURCHASE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNALEE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-251-4545
Mailing Address - Street 1:1029 MEDICAL CENTER CIR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1189
Mailing Address - Country:US
Mailing Address - Phone:270-251-4545
Mailing Address - Fax:270-251-4546
Practice Address - Street 1:1029 MEDICAL CENTER CIR
Practice Address - Street 2:SUITE 200
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1189
Practice Address - Country:US
Practice Address - Phone:270-251-4545
Practice Address - Fax:270-251-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPENDING208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty