Healthcare Provider Details

I. General information

NPI: 1194587824
Provider Name (Legal Business Name): KENNETH WILLIAM JACKSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A206
IDAHO FALLS ID
83404-7586
US

IV. Provider business mailing address

3200 CHANNING WAY STE A206
IDAHO FALLS ID
83404-7586
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2230
  • Fax: 208-561-8061
Mailing address:
  • Phone: 208-529-2230
  • Fax: 208-561-8061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7871497
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC075
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: