Individual
DR. KEVIN GORDON JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
7600 N 16TH ST STE 112, PHOENIX, AZ 85020-4446
(602) 830-0605
Mailing address
7600 N 16TH ST STE 112, PHOENIX, AZ 85020-4446
(602) 830-0605
Taxonomy
Speciality
Code
Description
License number
State
207QG0300X
Geriatric Medicine (Family Medicine) Physician
Primary
22105
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
428525
—
AZ
01
—
AZ0728320
BLUE CROSS OF ARIZONA
AZ
Enumeration date
06/11/2005
Last updated
04/13/2023
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