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General NPI Number Information
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NPI Number | 1851781520
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Entity Type | Organization
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Legal Business Name | JACKSON FAMILY DENTAL LLC
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Dates
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Enumeration Date | 02/02/2015
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Last Update Date | 10/08/2025
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Provider Practice Location Address
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Address Line | 8650 NE SHOAL CREEK VALLEY DRIVE
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City | KANSAS CITY
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State | MO
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Zip | 64157
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Country | US
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Telephone | 816-429-5799
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Fax | 816-245-7867
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Provider Business Mailing Address
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Address Line | 26 S VILLAGE DR
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City | LIBERTY
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State | MO
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Zip | 64068-2457
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Country | US
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Telephone | 816-429-5799
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JESSE LYNN JACKSON
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Credential | DDS
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Telephone | 816-429-5799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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