Provider Demographics
NPI:1235707837
Name:JACKSON, KARLA (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38835-0634
Mailing Address - Country:US
Mailing Address - Phone:662-416-8827
Mailing Address - Fax:
Practice Address - Street 1:3196 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9303
Practice Address - Country:US
Practice Address - Phone:662-284-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904658363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty