Provider Demographics
NPI:1801877907
Name:JACKSON, PAULA DEAUN (CRNP)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:DEAUN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:PAULA
Other - Middle Name:DEAUN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN, CRNP, LNC
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:484-628-1324
Mailing Address - Fax:
Practice Address - Street 1:160 E ERIE AVE
Practice Address - Street 2:SUITE 3311
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1011
Practice Address - Country:US
Practice Address - Phone:215-427-3871
Practice Address - Fax:215-492-8119
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00025500363LC1500X
PATP004745D363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1709420Medicaid
NJ9036407Medicaid
PA1709420Medicaid
S60760Medicare UPIN