1316977945 NPI number — DR. KIRK LEE JACKSON M.D.

Table of content: DR. KIRK LEE JACKSON M.D. (NPI 1316977945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316977945 NPI number — DR. KIRK LEE JACKSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
KIRK
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316977945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 870
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CULLMAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35056-0870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-230-8290
Provider Business Mailing Address Fax Number:
256-775-6305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2506 DANVILLE RD SW
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35603-4232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-350-6363
Provider Business Practice Location Address Fax Number:
256-350-6855
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  18273 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MD18273 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1316977945 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110160764 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51077099 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 77099 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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