Provider Demographics
NPI:1649848896
Name:JACKSON, AMY CHRISTINE
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:CHRISTINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-1158
Mailing Address - Country:US
Mailing Address - Phone:330-477-0975
Mailing Address - Fax:
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-729-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0029080363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care