Provider Demographics
NPI:1528570637
Name:JACKSON, JULIA M
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 MILL ST
Mailing Address - Street 2:
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-2219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2349 MILL ST
Practice Address - Street 2:
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-2219
Practice Address - Country:US
Practice Address - Phone:247-302-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017941363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily