Provider Demographics
NPI:1205824919
Name:JACKSON, WARREN KIETH (MD)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:KIETH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9140 WARD PARKWAY
Mailing Address - Street 2:STE 201
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114
Mailing Address - Country:US
Mailing Address - Phone:816-523-0066
Mailing Address - Fax:816-523-0034
Practice Address - Street 1:9140 WARD PARKWAY
Practice Address - Street 2:STE 201
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114
Practice Address - Country:US
Practice Address - Phone:816-523-0066
Practice Address - Fax:816-523-0034
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR6C88208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201749405Medicaid