Healthcare Provider Details

I. General information

NPI: 1306914296
Provider Name (Legal Business Name): KATHY JO JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W PATERSON ST
KALAMAZOO MI
49007-2557
US

IV. Provider business mailing address

1003 PINEHURST BLVD
KALAMAZOO MI
49006-2110
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-2641
  • Fax: 269-349-2898
Mailing address:
  • Phone: 269-349-2641
  • Fax: 269-349-2898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number070748
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: