Healthcare Provider Details

I. General information

NPI: 1851781520
Provider Name (Legal Business Name): JACKSON FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8650 NE SHOAL CREEK VALLEY DRIVE
KANSAS CITY MO
64157
US

IV. Provider business mailing address

26 S VILLAGE DR
LIBERTY MO
64068-2457
US

V. Phone/Fax

Practice location:
  • Phone: 816-429-5799
  • Fax: 816-245-7867
Mailing address:
  • Phone: 816-429-5799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JESSE LYNN JACKSON
Title or Position: OWNER
Credential: DDS
Phone: 816-429-5799