Provider Demographics
NPI:1356436273
Name:JACKSON, DEBORAH (CRNP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8875 CENTRE PARK DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2114
Mailing Address - Country:US
Mailing Address - Phone:410-730-1000
Mailing Address - Fax:410-730-8615
Practice Address - Street 1:8875 CENTRE PARK DR
Practice Address - Street 2:SUITE D
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2114
Practice Address - Country:US
Practice Address - Phone:410-730-1000
Practice Address - Fax:410-730-8615
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR048240363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD63697401OtherBLUE SHIELD
DCC4280003OtherBLUE SHIELD
136871YLZMedicare PIN
130249Medicare PIN