Provider Demographics
NPI:1851978183
Name:JACKSON, CAROLYN FAITH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:FAITH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 FRUTCHEY CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT BETHEL
Mailing Address - State:PA
Mailing Address - Zip Code:18343-6238
Mailing Address - Country:US
Mailing Address - Phone:202-441-5660
Mailing Address - Fax:
Practice Address - Street 1:4259 W SWAMP RD
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18902-1033
Practice Address - Country:US
Practice Address - Phone:202-441-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP0235532363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health