Healthcare Provider Details

I. General information

NPI: 1285180877
Provider Name (Legal Business Name): RICHARD MORGAN JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 3RD AVE
FORT KNOX KY
40121-2725
US

IV. Provider business mailing address

1307 3RD AVE
FORT KNOX KY
40121-2725
US

V. Phone/Fax

Practice location:
  • Phone: 520-672-1911
  • Fax:
Mailing address:
  • Phone: 520-672-1911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number79540
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: