Provider Demographics
NPI:1134261167
Name:JACKSON PHYSICIAN CORP
Entity type:Organization
Organization Name:JACKSON PHYSICIAN CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-593-5395
Mailing Address - Street 1:HWY 11 SOUTH
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41317
Mailing Address - Country:US
Mailing Address - Phone:606-593-5395
Mailing Address - Fax:606-593-5444
Practice Address - Street 1:HWY 11 SOUTH
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41314-9621
Practice Address - Country:US
Practice Address - Phone:606-693-0531
Practice Address - Fax:606-693-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65926594Medicaid