Provider Demographics
NPI:1720088347
Name:SUTHERLAND, JACKIE JEAN (DO)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:JEAN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MRS
Other - First Name:JACKIE
Other - Middle Name:JEAN
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:603 TEACO ROAD.
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3266
Mailing Address - Country:US
Mailing Address - Phone:573-717-7676
Mailing Address - Fax:573-717-7877
Practice Address - Street 1:603 TEACO ROAD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3266
Practice Address - Country:US
Practice Address - Phone:573-717-7676
Practice Address - Fax:573-717-7877
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003013951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209180900Medicaid
MO192785OtherBCBS
MO192785OtherBCBS
000092062Medicare PIN
I15681Medicare UPIN