Kenneth Dolen Jackson, MD

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

2008033152 Issued in MO

Practice address

930 Carondelet Dr
Suite 104
Kansas City, MO 64114-4855

Phone

(816) 941-2222

Fax

(816) 941-2282

NPI assigned

Dec 19, 2006

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MO

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

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.

• Prime Healthcare Kansas City - Physician Services LLC

  • Family Medicine Physician
  • Kansas City, MO
  • NPI 1427449487
  Medicare reassignment

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

{
    "created_epoch": "1166486400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1444867200000",
    "number": "1295898179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "930 CARONDELET DR 201",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641144698",
            "telephone_number": "816-941-2222",
            "fax_number": "816-941-2282"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "930 CARONDELET DR",
            "address_2": "SUITE 104",
            "city": "KANSAS CITY",
            "state": "MO",
            "postal_code": "641144855",
            "telephone_number": "816-941-2222",
            "fax_number": "816-941-2282"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KENNETH",
        "middle_name": "DOLEN",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-12-19",
        "last_updated": "2015-10-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Y00000X",
            "taxonomy_group": "",
            "desc": "Otolaryngology",
            "state": "KS",
            "license": "9406666",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "MO",
            "license": "2008033152",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jesse L Jackson, DDS
• Jessica Lenae Jackson
• Jodi K Jackson, MD
• Julia Todd Jackson, RN
• Katherine S.T. Jackson, LPC
• Keri D Jackson, AGACNP-BC
• Malinda Anne Jackson, OTR/L
• Mary Anne Jackson, MD
• Megan Jackson, APRN
• Melissa Marie Jackson, RN, IBCLC

• Surgery Physician in Kansas City, MO
• Providers in Kansas City, MO by specialty
• Surgery Physician in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.