Provider Demographics
NPI:1811044548
Name:JACKSON, ROGER P (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:P
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 CLAY EDWARDS DR STE 600
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3258
Mailing Address - Country:US
Mailing Address - Phone:816-471-6611
Mailing Address - Fax:816-471-6192
Practice Address - Street 1:2750 CLAY EDWARDS DR STE 600
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3258
Practice Address - Country:US
Practice Address - Phone:816-471-6611
Practice Address - Fax:816-471-6192
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5717207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
07979011OtherBCBS OF KC
200018411OtherRAILROAD MEDICARE
09-00221OtherUNITED HEALTHCARE
4571391OtherAETNA
4571391OtherAETNA
BJ0717263OtherDEA
200018411OtherRAILROAD MEDICARE