Provider Demographics
NPI:1447536370
Name:JACKSON, KIMBERLY NICOLE (DO)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 645409
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15264-5252
Mailing Address - Country:US
Mailing Address - Phone:330-386-6442
Mailing Address - Fax:330-386-3660
Practice Address - Street 1:2581 NORTH RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-3052
Practice Address - Country:US
Practice Address - Phone:234-287-6802
Practice Address - Fax:330-372-4437
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.011422207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine