Provider Demographics
NPI:1790907764
Name:JACKSON, KATHRYN LANO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LANO
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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Mailing Address - Street 1:1001 NUT TREE ROAD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687
Mailing Address - Country:US
Mailing Address - Phone:707-448-9350
Mailing Address - Fax:707-448-3572
Practice Address - Street 1:421 NUT TREE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3508
Practice Address - Country:US
Practice Address - Phone:707-624-7550
Practice Address - Fax:707-624-7501
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2014-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA441569363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA441569OtherCA BRN NURSE PRACTITIONER