Provider Demographics
NPI:1508561796
Name:JACKSON, KIMBERLY L
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
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 6098
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42702-6098
Mailing Address - Country:US
Mailing Address - Phone:270-982-7372
Mailing Address - Fax:270-982-7372
Practice Address - Street 1:415 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-1162
Practice Address - Country:US
Practice Address - Phone:270-982-7378
Practice Address - Fax:270-982-7379
Is Sole Proprietor?:No
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist