Healthcare Provider Details

I. General information

NPI: 1023219425
Provider Name (Legal Business Name): JACKSON PHYSICIAN CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 HIGHWAY 15 S STE 27
JACKSON KY
41339-8604
US

IV. Provider business mailing address

PO BOX 790
JACKSON KY
41339-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-693-0116
  • Fax: 606-693-0118
Mailing address:
  • Phone: 606-693-0531
  • Fax: 606-693-0535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number25492
License Number StateKY

VIII. Authorized Official

Name: LORETTA L CAMPBELL
Title or Position: CLINIC COORDINATOR
Credential:
Phone: 606-693-0531