Kenneth Jackson, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

5601001747 Issued in MI

Practice address

27901 Woodward Ave
Suite 300
Berkley, MI 48072-0919

Phone

(248) 837-2443

NPI assigned

Mar 29, 2007

Last updated

Jan 25, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Interoperability endpoints

• Direct secure messaging: kjackson19684@direct.beaumont.edu

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1175126400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1611532800000",
    "number": "1033238936",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "26901 BEAUMONT BLVD STE 3D",
            "city": "SOUTHFIELD",
            "state": "MI",
            "postal_code": "480333849",
            "fax_number": "947-522-0307"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "27901 WOODWARD AVE",
            "address_2": "SUITE 300",
            "city": "BERKLEY",
            "state": "MI",
            "postal_code": "480720919",
            "telephone_number": "248-837-2443"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KENNETH",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-03-29",
        "last_updated": "2021-01-25",
        "certification_date": "2021-01-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "MI",
            "license": "5601001747",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kjackson19684@direct.beaumont.edu",
            "affiliation": "N",
            "address_1": "27901 Woodward Ave",
            "address_2": "SUITE 300",
            "city": "Berkley",
            "state": "MI",
            "country_code": "US",
            "postal_code": "480720919",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Medical Physician Assistant in Berkley, MI
• Providers in Berkley, MI by specialty
• Medical Physician Assistant in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 25, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.