Provider Demographics
NPI:1629858261
Name:JACKSON, JAY ALLEN (RN)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:DONAHUE
Mailing Address - State:IA
Mailing Address - Zip Code:52746-9800
Mailing Address - Country:US
Mailing Address - Phone:239-888-3063
Mailing Address - Fax:
Practice Address - Street 1:601 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-1201
Practice Address - Country:US
Practice Address - Phone:563-652-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA116352163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice