Individual
DR. WILLIE MAE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2211 MAYFAIR DR, SUITE 409, OWENSBORO, KY 42301-4568
(270) 417-7980
(270) 417-7989
Mailing address
PO BOX 23229, OWENSBORO, KY 42304-3229
(270) 417-7980
(270) 417-7989
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
46400
KY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100137210
—
KY
Enumeration date
03/20/2009
Last updated
11/04/2020
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