Healthcare Provider Details

I. General information

NPI: 1730293705
Provider Name (Legal Business Name): ROBERT WAYNE JACKSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SIGLER AVE
MEMPHIS MO
63555
US

IV. Provider business mailing address

SIGLER AVE R1 BOX 54
MEMPHIS MO
63555
US

V. Phone/Fax

Practice location:
  • Phone: 660-465-2828
  • Fax: 660-465-2820
Mailing address:
  • Phone: 660-465-2828
  • Fax: 660-465-2820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberR6C73
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: