Provider Demographics
NPI:1104200930
Name:JACKSON, VANESSA RAE (CRNA)
Entity Type:Individual
Prefix:DR
First Name:VANESSA
Middle Name:RAE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 NE 82ND TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1332
Mailing Address - Country:US
Mailing Address - Phone:816-646-1242
Mailing Address - Fax:
Practice Address - Street 1:721 NE 82ND TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-1332
Practice Address - Country:US
Practice Address - Phone:816-646-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS557350367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered