Healthcare Provider Details

I. General information

NPI: 1790692416
Provider Name (Legal Business Name): JACKSON PARKER TEMPLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 BECKER DR
LAWRENCE KS
66047-1620
US

IV. Provider business mailing address

507 COLORADO ST UNIT 11
LAWRENCE KS
66044-6729
US

V. Phone/Fax

Practice location:
  • Phone: 816-806-7311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: