Provider Demographics
NPI:1558876680
Name:JACKSON, KAREN T (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 KENNETH RD STE 3
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-6344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1880 KENNETH RD STE 3
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-6344
Practice Address - Country:US
Practice Address - Phone:717-779-2612
Practice Address - Fax:717-779-0019
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005884363A00000X
PAMA061162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant