Provider Demographics
NPI:1770173890
Name:JACKSON, KAITLYN (DNAP, CRNA)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNAP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 SWEETBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-1550
Mailing Address - Country:US
Mailing Address - Phone:301-848-9975
Mailing Address - Fax:
Practice Address - Street 1:1701 N GEORGE MASON DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3610
Practice Address - Country:US
Practice Address - Phone:703-558-2438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-22
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180806367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered