Provider Demographics
NPI:1891027538
Name:JACKSON, ETHELYN L (FNP)
Entity Type:Individual
Prefix:
First Name:ETHELYN
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1381 S MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2846
Mailing Address - Country:US
Mailing Address - Phone:830-249-9424
Mailing Address - Fax:
Practice Address - Street 1:LANDSTUHL MEDICAL REGIONAL CENTER
Practice Address - Street 2:UNIT 3310,0
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-7363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX717137363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily