Basic Information
| Provider Information | |||||||||
| NPI: | 1427686765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KATY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 RAINBOW BLVD # MS 2027 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135883974 | ||||||||
| FaxNumber: | 9135886055 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 RAINBOW BLVD # MS 2027 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661608500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135883974 | ||||||||
| FaxNumber: | 9135886055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2020 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 94-10215 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.