Provider Demographics
NPI:1548569056
Name:JACKSON, KYLE JEFFERSON (DO)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JEFFERSON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S FLEISHEL AVE
Mailing Address - Street 2:SUITE 327
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2004
Mailing Address - Country:US
Mailing Address - Phone:903-510-1173
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:SUITE 327
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-510-1173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6851207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8GA283OtherBCBS
TX360453001Medicaid
TX75-2616977-123OtherTRICARE
TXP01697215OtherRAIL ROAD MEDICARE
TX514020YMAFMedicare PIN