Provider Demographics
NPI:1306372842
Name:JACKSON, TERESA LYNNE (FNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-2258
Mailing Address - Country:US
Mailing Address - Phone:620-660-2105
Mailing Address - Fax:
Practice Address - Street 1:118 N SUMMIT ST
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-2258
Practice Address - Country:US
Practice Address - Phone:620-506-5005
Practice Address - Fax:620-506-5002
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5377626021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5377626021OtherFNP NUMBER