Provider Demographics
NPI:1700176617
Name:JACKSON, ALAN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:DAVID
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 1:3950 KRESGE WAY
Mailing Address - Street 2:STE 308
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4637
Mailing Address - Country:US
Mailing Address - Phone:502-895-8911
Mailing Address - Fax:
Practice Address - Street 1:4000 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4605
Practice Address - Country:US
Practice Address - Phone:502-895-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY47185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program