Provider Demographics
NPI:1073619037
Name:JACKSON, KATHLEEN J (RN-APN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN-APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 WCUTHBERT BLVD UNIT 26 STE A
Mailing Address - Street 2:UNIT 26, SUITE A
Mailing Address - City:WESTMONT
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-4197
Mailing Address - Country:US
Mailing Address - Phone:856-946-5180
Mailing Address - Fax:856-946-5181
Practice Address - Street 1:602 W CUTHBERT BLVD UNIT 26
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-3642
Practice Address - Country:US
Practice Address - Phone:856-946-5180
Practice Address - Fax:856-946-5181
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP001754C363L00000X
NJ26NN06425500363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8780803Medicaid
NJP3845837/2854869OtherOXFORD/UNITED HLTH.
NJ9765851OtherCIGNA
NJ60037187OtherHORIZON NJ HEALTH
NJP3845837/2854869OtherOXFORD/UNITED HLTH.
NJ056129DDMMedicare PIN
NJ9765851OtherCIGNA
NJP54083Medicare UPIN