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General NPI Number Information
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NPI Number | 1871986083
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Entity Type | Individual
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Provider Name | KEVIN W JACKSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 03/12/2015
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Last Update Date | 04/02/2024
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Provider Practice Location Address
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Address Line | 801 PRO DR STE D1
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City | CELINA
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State | OH
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Zip | 45822-3307
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Country | US
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Telephone | 419-586-6489
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Fax | 419-586-8509
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Provider Business Mailing Address
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Address Line | 1140 S KNOXVILLE AVE STE D
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City | SAINT MARYS
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State | OH
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Zip | 45885-2609
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Country | US
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Telephone | 419-300-1129
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 50.004297RX
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License Number State | OH
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