MEDICARE: DR. KENNETH DOUGLAS JACKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	12522	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	12522	OTHER	AZ	LICENSE

General Provider Information

NPI Number	:	1073510491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH DOUGLAS JACKSON M.D.

Provider Business Mailing Address
First Line	:	1739 E BEVERLY AVE
Second Line	:	SUITE 201
City	:	KINGMAN
State	:	AZ
Zip	:	86401-3593
Country	:	US
Telephone Number	:	928-692-3456
Fax Number	:	928-692-7071

Provider Business Practice Location Address
First Line	:	1739 E BEVERLY AVE
Second Line	:	SUITE 201
City	:	KINGMAN
State	:	AZ
Zip	:	86401-3593
Country	:	US
Telephone Number	:	928-692-3456
Fax Number	:	928-692-7071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	03/07/2023

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Directions to “ DR. KENNETH DOUGLAS JACKSON M.D.” Practice Location

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