Provider Demographics
NPI:1831165166
Name:JACKSON, CHERYL ANNE (NP)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HIGHLAND CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-1237
Mailing Address - Country:US
Mailing Address - Phone:570-674-2268
Mailing Address - Fax:
Practice Address - Street 1:401 SHICKSHINNEY LAKE ROAD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON MILLS
Practice Address - State:PA
Practice Address - Zip Code:18622-0046
Practice Address - Country:US
Practice Address - Phone:570-864-3191
Practice Address - Fax:570-864-2569
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005790B363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50072326OtherKEYSTONE CBC
PA1019794280001Medicaid
PAQ12223Medicare UPIN
PA077688WDBMedicare PIN