Healthcare Provider Details

I. General information

NPI: 1720924749
Provider Name (Legal Business Name): JACKSON ONESOURCE SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 GOULD STREET
KEWANEE MO
63860
US

IV. Provider business mailing address

PO BOX 115
KEWANEE MO
63860-0115
US

V. Phone/Fax

Practice location:
  • Phone: 573-748-8198
  • Fax:
Mailing address:
  • Phone: 573-748-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEASIA NEWSON JACKSON
Title or Position: OWNER
Credential: CPT
Phone: 573-748-8198