Provider Demographics
NPI:1205950961
Name:JACKSON FAMILY CLINIC, INC
Entity type:Organization
Organization Name:JACKSON FAMILY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETT
Authorized Official - Middle Name:D
Authorized Official - Last Name:ASHER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-243-8408
Mailing Address - Street 1:545 BROADRIDGE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755
Mailing Address - Country:US
Mailing Address - Phone:573-243-8408
Mailing Address - Fax:573-243-0445
Practice Address - Street 1:545 BROADRIDGE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755
Practice Address - Country:US
Practice Address - Phone:573-243-8408
Practice Address - Fax:573-243-0445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOCO9028OtherRR MEDICARE
MO505190207Medicaid
MO505190207Medicaid