Provider Demographics
NPI:1073525150
Name:JACKSON, PATRICIA L (APRN)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1252 N 22ND ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5306
Mailing Address - Country:US
Mailing Address - Phone:307-745-5364
Mailing Address - Fax:
Practice Address - Street 1:1252 N 22ND ST UNIT A
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5306
Practice Address - Country:US
Practice Address - Phone:307-745-5364
Practice Address - Fax:307-745-4164
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY43087363L00000X
CT4708363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily