MEDICARE: DR. KIMBERLY ANN FUNCHES-JACKSON M.D.

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	207Q00000X	Family Medicine Physician	056705	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	056705	OTHER	GA	GA LICENSE
2	26806	OTHER	AL	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1497705123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY ANN FUNCHES-JACKSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 1045
Second Line	:
City	:	PHENIX CITY
State	:	AL
Zip	:	36868-1045
Country	:	US
Telephone Number	:	334-291-5255
Fax Number	:

Provider Business Practice Location Address
First Line	:	1810 STADIUM DR
Second Line	:	SUITE 210
City	:	PHENIX CITY
State	:	AL
Zip	:	36867-3177
Country	:	US
Telephone Number	:	334-297-1085
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	02/27/2017

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