Provider Demographics
NPI:1295898179
Name:JACKSON, KENNETH DOLEN (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DOLEN
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 1:930 CARONDELET DR 201
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-4698
Mailing Address - Country:US
Mailing Address - Phone:816-941-2222
Mailing Address - Fax:816-941-2282
Practice Address - Street 1:930 CARONDELET DR
Practice Address - Street 2:SUITE 104
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-4855
Practice Address - Country:US
Practice Address - Phone:816-941-2222
Practice Address - Fax:816-941-2282
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9406666207Y00000X
MO2008033152208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology