Provider Demographics
NPI:1205460045
Name:JACKSON, AMANDA (CPNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 W MOUNT VERNON ST STE 220
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-9613
Mailing Address - Country:US
Mailing Address - Phone:417-724-5437
Mailing Address - Fax:
Practice Address - Street 1:940 W MOUNT VERNON ST STE 220
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-9613
Practice Address - Country:US
Practice Address - Phone:417-724-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011022742163W00000X
MO2020008008363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse