MEDICARE: MRS. KATHLEEN ANNE 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	207R00000X	Internal Medicine Physician	MD17495	OR

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	:	1548236029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN ANNE JACKSON M.D.

Provider Business Mailing Address
First Line	:	147 S 52ND PL
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-6210
Country	:	US
Telephone Number	:	541-746-1166
Fax Number	:	541-746-6736

Provider Business Practice Location Address
First Line	:	147 S 52ND PL
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-6210
Country	:	US
Telephone Number	:	541-746-1166
Fax Number	:	541-746-6736

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

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	12/21/2016

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