Provider Demographics
NPI:1497705123
Name:FUNCHES-JACKSON, KIMBERLY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANN
Last Name:FUNCHES-JACKSON
Suffix:
Gender:F
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:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36868-1045
Mailing Address - Country:US
Mailing Address - Phone:334-291-5255
Mailing Address - Fax:
Practice Address - Street 1:1810 STADIUM DR
Practice Address - Street 2:SUITE 210
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3177
Practice Address - Country:US
Practice Address - Phone:334-297-1085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056705OtherGA LICENSE
AL26806OtherSTATE MEDICAL LICENSE
AL26806OtherSTATE MEDICAL LICENSE