Provider Demographics
NPI:1184979098
Name:JACKSON, TARA (APRN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7221 HOLMES RD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1675
Mailing Address - Country:US
Mailing Address - Phone:816-276-7410
Mailing Address - Fax:
Practice Address - Street 1:6675 HOLMES RD
Practice Address - Street 2:SUITE 400
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1150
Practice Address - Country:US
Practice Address - Phone:816-276-7410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75820-112363LF0000X
MO2012041039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily