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General NPI Number Information
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NPI Number | 1073525861
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Entity Type | Individual
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Provider Name | JACKIE D MAXEY MD
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Gender | Male
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 08/15/2014
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Provider Practice Location Address
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Address Line | 102 PROFESSIONAL DR SUITE #2
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City | LONDON
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State | KY
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Zip | 40741-8857
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Country | US
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Telephone | 606-878-9611
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Fax | 606-862-7565
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Provider Business Mailing Address
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Address Line | PO BOX 1676
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City | LONDON
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State | KY
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Zip | 40743-1676
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Country | US
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Telephone | 606-878-9611
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Fax | 606-862-7565
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 35548
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License Number State | KY
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