MEDICARE: JACKSON MEDICAL CENTER PC

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

General Provider Information

NPI Number	:	1508048125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MEDICAL CENTER PC

Provider Business Mailing Address
First Line	:	2387 W JACKSON BLVD
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-3024
Country	:	US
Telephone Number	:	573-243-9288
Fax Number	:	573-204-7074

Provider Business Practice Location Address
First Line	:	2387 W JACKSON BLVD
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-3024
Country	:	US
Telephone Number	:	573-243-9288
Fax Number	:	573-204-7074

Authorized Official
Title or Position	:	MANAGER
Name	:	STACEY L CANTRELL
Credential	:
Telephone Number	:	573-335-1779

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	10/07/2020

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Directions to “JACKSON MEDICAL CENTER PC ” Practice Location

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