Individual
DR. KENNETH DOUGLAS JACKSON
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1739 E BEVERLY AVE, SUITE 201, KINGMAN, AZ 86401-3593
(928) 692-3456
(928) 692-7071
Mailing address
1739 E BEVERLY AVE, SUITE 201, KINGMAN, AZ 86401-3593
(928) 692-3456
(928) 692-7071
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
12522
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12522
LICENSE
AZ
05
—
209991
—
AZ
Enumeration date
06/30/2005
Last updated
03/07/2023
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