Provider Demographics
NPI:1790775526
Name:JACKSON, JULIE A (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-1701
Mailing Address - Country:US
Mailing Address - Phone:606-574-8409
Mailing Address - Fax:
Practice Address - Street 1:37 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1701
Practice Address - Country:US
Practice Address - Phone:606-574-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4452P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78014487Medicaid