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General NPI Number Information
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NPI Number | 1174083810
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Entity Type | Individual
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Provider Name | KENNETH JASON JACKSON MD
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Gender | Male
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Dates
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Enumeration Date | 03/20/2019
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Last Update Date | 08/19/2022
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Provider Practice Location Address
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Address Line | 18 OLD ETNA RD
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City | LEBANON
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State | NH
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Zip | 03766-1937
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Country | US
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Telephone | 603-650-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 18 OLD ETNA RD
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City | LEBANON
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State | NH
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Zip | 03766-1937
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Country | US
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Telephone |
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Fax |
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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 | 22456
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License Number State | NH
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