Doctor Name: | FARRIS JACKSON |
NPI Number: | 1083618904 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | R9F09 |
Business Practice Address: | 1011 Bowles Ave Suite 300 Fenton, MO - 630262395 |
Business Phone Number: | 6364965030 |
Business Fax Number: | 6364965025 |
Mailing Address: | 1011 Bowles Ave, Suite 300 FENTON |
State: | MO |
Postal Code: | 630262395 |
Phone Number: | 6364965030 |
Fax Number: | 6364965025 |
NPI Enumeration Date: | 06/09/2005 |
NPI Last Update Date: | 08/01/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 174400000X |
License Number: | R9F09 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MO |
Taxonomy Type: | Other Service Providers |
Taxonomy Classification: | Specialist |
Taxonomy Specialization: | |
Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |