Provider Demographics
NPI:1639812670
Name:JACKSON, MICHAEL L (BA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 W MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2065
Mailing Address - Country:US
Mailing Address - Phone:859-245-2400
Mailing Address - Fax:859-245-2443
Practice Address - Street 1:1353 W MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2065
Practice Address - Country:US
Practice Address - Phone:859-245-2400
Practice Address - Fax:859-245-2443
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator