MEDICARE: DOROTHY JEAN JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	R8B55	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023004009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOROTHY JEAN JACKSON MD

Provider Business Mailing Address
First Line	:	6220 N CYPRESS AVE
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-5051
Country	:	US
Telephone Number	:	816-679-9150
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 NW VIVION RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64150-1502
Country	:	US
Telephone Number	:	816-599-5050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	06/11/2025

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