Provider Demographics
NPI:1790055465
Name:JACKSON, SARA W (PA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:DANIELLE
Other - Last Name:WALDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:479 THOMAS JONES WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2552
Mailing Address - Country:US
Mailing Address - Phone:610-280-9999
Mailing Address - Fax:215-615-1320
Practice Address - Street 1:479 THOMAS JONES WAY STE 300
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2552
Practice Address - Country:US
Practice Address - Phone:610-280-9999
Practice Address - Fax:215-615-1320
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9106211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFZ331YMedicare PIN