Provider Demographics
NPI:1700827383
Name:JACKSON, JENNIFER (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
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 1:2241 N 189TH CIR W
Mailing Address - Street 2:
Mailing Address - City:COLWICH
Mailing Address - State:KS
Mailing Address - Zip Code:67030-9728
Mailing Address - Country:US
Mailing Address - Phone:316-789-4378
Mailing Address - Fax:
Practice Address - Street 1:2241 N 189TH CIR W
Practice Address - Street 2:
Practice Address - City:COLWICH
Practice Address - State:KS
Practice Address - Zip Code:67030-9728
Practice Address - Country:US
Practice Address - Phone:316-789-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0429383207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200004010AMedicaid
KS100088840BMedicaid
KS200004010AMedicaid
KSH91654Medicare UPIN
KS103071Medicare ID - Type UnspecifiedKANSAS PART B
KSP00052327Medicare ID - Type UnspecifiedRAILROAD MEDICARE