Provider Demographics
NPI:1295500999
Name:JACKSON, AMY (AGACNP-BC, APN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AGACNP-BC, APN
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:ACEVEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2028 HUNTINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1510
Mailing Address - Country:US
Mailing Address - Phone:501-617-3931
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY53523363L00000X, 363LG0600X
COAPN.0999288-NP363L00000X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care