| Doctor Name: | KENNETH JACKSON |
| NPI Number: | 1033238936 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 5601001747 |
| Business Practice Address: | 27901 Woodward Ave Suite 300 Berkley, MI - 480720919 |
| Business Phone Number: | 2488372443 |
| Business Fax Number: | |
| Mailing Address: | 130 Town Center Dr, Ste 203 TROY |
| State: | MI |
| Postal Code: | 480841744 |
| Phone Number: | 2485858233 |
| Fax Number: | 2485858266 |
| NPI Enumeration Date: | 03/29/2007 |
| NPI Last Update Date: | 06/08/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 5601001747 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |