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General NPI Number Information
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NPI Number | 1790213676
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Entity Type | Organization
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Legal Business Name | JACKSON PRIMARY CARE LLC
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Dates
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Enumeration Date | 05/23/2017
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Last Update Date | 05/25/2017
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Provider Practice Location Address
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Address Line | 2685 E MAIN ST STE A
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City | JACKSON
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State | MO
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Zip | 63755-2474
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Country | US
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Telephone | 573-204-1400
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Fax | 573-204-1480
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Provider Business Mailing Address
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Address Line | 2685 E MAIN ST STE A
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City | JACKSON
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State | MO
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Zip | 63755-2474
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Country | US
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Telephone | 573-204-1400
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Fax | 573-204-1480
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JOAN L MAYBERRY
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Credential |
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Telephone | 573-204-1400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 106442
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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