Provider Demographics
NPI:1558360743
Name:JACKSON, JAY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9119 W 74TH ST
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2215
Mailing Address - Country:US
Mailing Address - Phone:913-789-3290
Mailing Address - Fax:913-789-3208
Practice Address - Street 1:9119 W 74TH ST
Practice Address - Street 2:SUITE 350
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2215
Practice Address - Country:US
Practice Address - Phone:913-789-3290
Practice Address - Fax:913-789-3208
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8D86207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1558360743Medicaid
MO201986726Medicaid
KS100168130JMedicaid
MO1558360743Medicaid
MO201986726Medicaid
KS100168130JMedicaid
MOY056591Medicare PIN
MO4016591Medicare ID - Type Unspecified