MEDICARE: JACKSON PHYSICIAN CORP

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	02940	KY

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

General Provider Information

NPI Number	:	1134261167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PHYSICIAN CORP

Provider Business Mailing Address
First Line	:	HWY 11 SOUTH
Second Line	:
City	:	BOONEVILLE
State	:	KY
Zip	:	41317
Country	:	US
Telephone Number	:	606-593-5395
Fax Number	:	606-593-5444

Provider Business Practice Location Address
First Line	:	HWY 11 SOUTH
Second Line	:
City	:	BOONEVILLE
State	:	KY
Zip	:	41314-9621
Country	:	US
Telephone Number	:	606-693-0531
Fax Number	:	606-693-0535

Authorized Official
Title or Position	:	CLINIC COORDINATOR
Name	:	LORETTA L CAMPBELL
Credential	:
Telephone Number	:	606-593-5395

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	08/22/2020

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Directions to “JACKSON PHYSICIAN CORP ” Practice Location

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