Provider Demographics
NPI:1891880100
Name:JACKSON, REGULA R (CNM, OB-GYN NP)
Entity Type:Individual
Prefix:
First Name:REGULA
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM, OB-GYN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O.BOX 31001-0698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1511
Mailing Address - Fax:602-263-1637
Practice Address - Street 1:4212 NORTH 16TH STREET
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1511
Practice Address - Fax:602-263-1637
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN057918363LX0001X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ451667Medicaid
AZAZ0145750OtherBCBS
AZAZ0145750OtherBCBS
AZ030078Medicare Oscar/Certification
AZP57981Medicare UPIN