Kevin Gordon Jackson, M.D.

Primary specialty

Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X

License

22105 Issued in AZ

Practice address

7600 N 16TH St Ste 112
Phoenix, AZ 85020-4446

Phone

(602) 830-0605

NPI assigned

Jun 11, 2005

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

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in AZ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

• Copper Sky Hospice LLC

  • Community Based Hospice Care Agency
  • Phoenix, AZ
  • NPI 1073199394

  Contracted Managing Employee

  CMS ownership

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Copper Sky Hospice LLC

  • Community Based Hospice Care Agency
  • Phoenix, AZ
  • NPI 1073199394

  Family Medicine

  NPD
• University Health Physicians

  • Internal Medicine Physician
  • Kansas City, MO
  • NPI 1669456257

  Family Medicine

  NPD (past)

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

{
    "created_epoch": "1118448000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1681344000000",
    "number": "1225032782",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7600 N 16TH ST STE 112",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850204446",
            "telephone_number": "602-830-0605"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7600 N 16TH ST STE 112",
            "city": "PHOENIX",
            "state": "AZ",
            "postal_code": "850204446",
            "telephone_number": "602-830-0605"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KEVIN",
        "middle_name": "GORDON",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-06-11",
        "last_updated": "2023-04-13",
        "certification_date": "2023-04-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "AZ",
            "license": "22105",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "428525",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS OF ARIZONA",
            "identifier": "AZ0728320",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Dorothea Ann-Marie Jackson, MD
• Fatima Jackson
• Ginece Jasmine Jackson, MD
• Jamie Azure Lillian Jackson
• Keenan Jackson
• Kierra Lashay Jackson
• Larhonda Jackson
• Lynetta Jean Jackson
• Mac Roy Jackson III, DMD
• Marlene Jackson, SLPA

• Geriatric Medicine (Family Medicine) Physician in Phoenix, AZ
• Providers in Phoenix, AZ by specialty
• Geriatric Medicine (Family Medicine) Physician in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.