Provider Demographics
NPI:1497726806
Name:JACKSON-KING, KELLY ROBIN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ROBIN
Last Name:JACKSON-KING
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 1:3196 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-2305
Mailing Address - Country:US
Mailing Address - Phone:702-255-3547
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2305
Practice Address - Country:US
Practice Address - Phone:702-255-3547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9540207V00000X
FLME125609207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2018359Medicaid
NV3102659OtherMEDICAID
NV3102659OtherMEDICAID
NV36424Medicare PIN