Provider Demographics
NPI:1518553403
Name:CRAWFORD, JACKIE R (NP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:R
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUEILINE
Other - Middle Name:R
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1701 SPRING ST STE B
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-2930
Mailing Address - Country:US
Mailing Address - Phone:812-284-2273
Mailing Address - Fax:812-284-2279
Practice Address - Street 1:1701 SPRING ST STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-2930
Practice Address - Country:US
Practice Address - Phone:812-284-2273
Practice Address - Fax:812-284-2279
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28156286A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily