Basic Information
| Provider Information | |||||||||
| NPI: | 1104143072 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KEEGAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634040 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3245 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2010 | ||||||||
| LastUpdateDate: | 10/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 54140 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7867 | AK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.