Healthcare Provider Details

I. General information

NPI: 1033279864
Provider Name (Legal Business Name): JAMES EDWARD JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E MAIN ST
MOREHEAD KY
40351-1620
US

IV. Provider business mailing address

212 E MAIN ST
MOREHEAD KY
40351-1620
US

V. Phone/Fax

Practice location:
  • Phone: 606-784-8518
  • Fax: 606-784-8899
Mailing address:
  • Phone: 606-784-8518
  • Fax: 606-784-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14467
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: