Provider Demographics
NPI:1487606943
Name:JACKSON, KENNETH WADE JR (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WADE
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5698
Mailing Address - Fax:
Practice Address - Street 1:15 SKYLAND INN DR FL 2
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-7714
Practice Address - Country:US
Practice Address - Phone:828-654-5005
Practice Address - Fax:828-654-3257
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9801313207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2169383OtherUNITED HEALTHCARE
NC11453742OtherCAQH
NC136RMOtherBLUE CROSS
NC89136RMMedicaid
NC2026512Medicare PIN
NC136RMOtherBLUE CROSS