Basic Information
| Provider Information | |||||||||
| NPI: | 1306914296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 PINEHURST BLVD | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490062110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | 2693492898 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | 2693492898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 208000000X | 070748 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.