Provider Demographics
NPI:1952403065
Name:JACKSON, BECKY DIXON (NURSE ANESTHETIST)
Entity Type:Individual
Prefix:MS
First Name:BECKY
Middle Name:DIXON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE ANESTHETIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7397
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29804-7397
Mailing Address - Country:US
Mailing Address - Phone:336-553-1659
Mailing Address - Fax:336-553-3994
Practice Address - Street 1:302 UNIVERSITY PKWY
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6302
Practice Address - Country:US
Practice Address - Phone:336-553-1659
Practice Address - Fax:336-553-3994
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2782367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0576Medicaid
SCQ29280Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL