Healthcare Provider Details

I. General information

NPI: 1619961380
Provider Name (Legal Business Name): JACKSON PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 10/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2685 E MAIN ST SUITE A STE A
JACKSON MO
63755
US

IV. Provider business mailing address

2685 E MAIN ST SUITE A STE A
JACKSON MO
63755
US

V. Phone/Fax

Practice location:
  • Phone: 573-204-1400
  • Fax: 573-204-1480
Mailing address:
  • Phone: 573-204-1400
  • Fax: 573-204-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEANNA M SIEMER
Title or Position: OWNER
Credential: MD
Phone: 573-204-1400