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General NPI Number Information
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NPI Number | 1639359565
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Entity Type | Organization
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Legal Business Name | JACKSON HEALTHCARE
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Dates
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Enumeration Date | 11/08/2007
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Last Update Date | 11/08/2007
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Provider Practice Location Address
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Address Line | 148 MIDLAND BLVD
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City | SHELBYVILLE
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State | KY
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Zip | 40065-9734
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Country | US
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Telephone | 502-647-1958
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Fax | 502-647-1940
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Provider Business Mailing Address
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Address Line | 148 MIDLAND BLVD
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City | SHELBYVILLE
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State | KY
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Zip | 40065-9734
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Country | US
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Telephone | 502-647-1958
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Fax | 502-647-1940
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Authorized Official
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Title or Position | OWNER/DOCTOR
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Name | DR. WILLIAM J JACKSON
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Credential | MD
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Telephone | 502-647-1958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 18425
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License Number State | KY
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