Provider Demographics
NPI:1164849352
Name:JACKSON, KYLE (MD, PHD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 SILVERSTEIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:10104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-615-4949
Mailing Address - Fax:215-662-2244
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:4 SILVERSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:10104-4206
Practice Address - Country:US
Practice Address - Phone:215-615-4949
Practice Address - Fax:215-662-2244
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD485481208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery