Provider Demographics
NPI:1518906320
Name:JACKSON, EILEEN KEENAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:KEENAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:EILEEN
Other - Middle Name:GRAHAM
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:51 E MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646
Mailing Address - Country:US
Mailing Address - Phone:435-283-4076
Mailing Address - Fax:435-283-4078
Practice Address - Street 1:51 E MAIN ST.
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646
Practice Address - Country:US
Practice Address - Phone:435-436-5250
Practice Address - Fax:435-436-5262
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3687031205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063331Medicare PIN
UTI23563Medicare UPIN
UT000055844Medicare PIN