Provider Demographics
NPI:1790213676
Name:JACKSON PRIMARY CARE LLC
Entity Type:Organization
Organization Name:JACKSON PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-204-1400
Mailing Address - Street 1:2685 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2474
Mailing Address - Country:US
Mailing Address - Phone:573-204-1400
Mailing Address - Fax:573-204-1480
Practice Address - Street 1:2685 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-2474
Practice Address - Country:US
Practice Address - Phone:573-204-1400
Practice Address - Fax:573-204-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
MO106442261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health