Basic Information
| Provider Information | |||||||||
| NPI: | 1023063823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | WOODSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437930658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404725167 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 37984 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | WOODSFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437939247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404720757 | ||||||||
| FaxNumber: | 7404720283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP 01675 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | MJ0814702 | 01 | OH | DEA REGISTRATION NUMBER | OTHER | JA2027601 | 01 | OH | MEDICARE FQHC PIN | OTHER |