Provider Demographics
NPI:1861472953
Name:JACKSON, AUDRA L (CRNA)
Entity Type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1002 GEMINI ST STE 128
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-2746
Mailing Address - Country:US
Mailing Address - Phone:281-218-9515
Mailing Address - Fax:281-218-9534
Practice Address - Street 1:1002 GEMINI ST STE 128
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2746
Practice Address - Country:US
Practice Address - Phone:281-218-9515
Practice Address - Fax:281-218-9534
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142779367500000X
MOAP12634367500000X
TXAP126342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
MOP00602283Medicare PIN
IL$$$$$$$$$001Medicaid