Provider Demographics
NPI:1639130479
Name:ROWE, JACKIE CLAYTON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:CLAYTON
Last Name:ROWE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 627A
Mailing Address - Street 2:
Mailing Address - City:MARBLE HILL
Mailing Address - State:MO
Mailing Address - Zip Code:63764-9724
Mailing Address - Country:US
Mailing Address - Phone:573-238-4535
Mailing Address - Fax:
Practice Address - Street 1:3241 PERCY DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4901
Practice Address - Country:US
Practice Address - Phone:573-334-1222
Practice Address - Fax:573-334-3532
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109722367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO44696OtherAANA NUMBER
MO109722OtherNURSING LICENSE