Provider Demographics
NPI:1629330790
Name:JACKSON, DAWN M (MD)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9658 W 117TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-3134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6675 HOLMES RD
Practice Address - Street 2:SUITE 450
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1150
Practice Address - Country:US
Practice Address - Phone:816-276-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012017896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine