Provider Demographics
NPI:1619135373
Name:JACKSON, MOLLIE J (DO)
Entity Type:Individual
Prefix:MS
First Name:MOLLIE
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:DEPARTMENT OF GASTROENTEROLOGY
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-8500
Mailing Address - Country:US
Mailing Address - Phone:913-588-3283
Mailing Address - Fax:913-588-3975
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:DEPARTMENT OF GASTROENTEROLOGY
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-8500
Practice Address - Country:US
Practice Address - Phone:913-588-3283
Practice Address - Fax:913-588-3975
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003644207R00000X
IN02003644A208M00000X, 207R00000X
KS05-37265207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200984700Medicaid
KS200984700Medicaid
INM400018252Medicare PIN
IN200984700Medicaid