Provider Demographics
NPI:1538662374
Name:JACKSON, KEVIN JEVON (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JEVON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 CHESTNUT ST APT 1212
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-6119
Mailing Address - Country:US
Mailing Address - Phone:251-232-0156
Mailing Address - Fax:
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2022-01286207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program