MEDICARE: DR. MICHAEL D 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	04-19573	KS

General Provider Information

NPI Number	:	1255383741
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL D JACKSON M.D.

Provider Business Mailing Address
First Line	:	PO BOX 803929
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64180-3929
Country	:	US
Telephone Number	:	800-953-0104
Fax Number	:	303-765-6670

Provider Business Practice Location Address
First Line	:	602 N 6TH ST
Second Line	:
City	:	GARDEN CITY
State	:	KS
Zip	:	67846-5509
Country	:	US
Telephone Number	:	620-272-2519
Fax Number	:

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

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	06/03/2024

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