Provider Demographics
NPI:1235692112
Name:JACKSON, DANA A (PA-C)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 KS HWY 96
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530
Mailing Address - Country:US
Mailing Address - Phone:402-770-8575
Mailing Address - Fax:
Practice Address - Street 1:1514 KS HWY 96
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:402-770-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2366363A00000X
KS15-02445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant