Provider Demographics
NPI:1275976169
Name:JACKSON, KATHERINE ANNE (PNP)
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PNP
Mailing Address - Street 1:1100 W 39TH 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-3902
Mailing Address - Country:US
Mailing Address - Phone:512-454-4545
Mailing Address - Fax:
Practice Address - Street 1:1100 W 39TH 1/2 ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-3902
Practice Address - Country:US
Practice Address - Phone:512-454-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX781377363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics