Basic Information
| Provider Information | |||||||||
| NPI: | 1437771888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801143 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641801143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733315583 | ||||||||
| FaxNumber: | 5733315079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 GORDONVILLE RD STE 358 | ||||||||
| Address2: | |||||||||
| City: | CAPE GIRARDEAU | ||||||||
| State: | MO | ||||||||
| PostalCode: | 637035095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733313155 | ||||||||
| FaxNumber: | 5733315096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2020 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2021043554 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 085008569 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 2021043554 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.