Basic Information
| Provider Information | |||||||||
| NPI: | 1447658919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 E STONE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232241110 | ||||||||
| FaxNumber: | 4232241130 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W STONE DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376606027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243701 | ||||||||
| FaxNumber: | 4232243709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2014 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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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 | 163W00000X | 182185 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 19521 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1447658919 | 05 | VA | MEDICAID | Q010785 | 05 | TN | MEDICAID |