Healthcare Provider Details

I. General information

NPI: 1235412982
Provider Name (Legal Business Name): KELLY JACKSON JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELIZABETH JACKSON

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 LINCOLN DR
HERRIN IL
62948-6334
US

IV. Provider business mailing address

4787 ALBEN BARKLEY DR SUITE 103
PADUCAH KY
42001-6789
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-6800
  • Fax: 618-997-1187
Mailing address:
  • Phone: 270-442-9461
  • Fax: 270-441-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1637
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: