Provider Demographics
NPI:1790150688
Name:JACKSON, POLLY REBECCA (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:REBECCA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3127
Mailing Address - Country:US
Mailing Address - Phone:636-239-8231
Mailing Address - Fax:
Practice Address - Street 1:901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3127
Practice Address - Country:US
Practice Address - Phone:636-239-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-03
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015041436363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care