Provider Demographics
NPI:1043649627
Name:JACKSON, PHYLLIS E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:E
Last Name:JACKSON
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:300 EVERGREEN DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1059
Mailing Address - Country:US
Mailing Address - Phone:610-874-1184
Mailing Address - Fax:610-874-4258
Practice Address - Street 1:300 EVERGREEN DR
Practice Address - Street 2:SUITE 150
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1059
Practice Address - Country:US
Practice Address - Phone:610-874-1184
Practice Address - Fax:610-874-4258
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2014-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMA000510L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant