Individual
DERRICK JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
11000 DELAWARE PKWY APT 2307, KANSAS CITY, KS 66109-3567
(913) 908-0397
Mailing address
PO BOX 25562, KANSAS CITY, MO 64119-0862
(913) 908-0397
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
K02110954
KS
Other
Enumeration date
10/31/2022
Last updated
11/01/2022
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