Healthcare Provider Details

I. General information

NPI: 1437771888
Provider Name (Legal Business Name): JENNA M JACKSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 GORDONVILLE RD STE 358
CAPE GIRARDEAU MO
63703-5095
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-331-3155
  • Fax: 573-331-5096
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2021043554
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085008569
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: