Basic Information
| Provider Information | |||||||||
| NPI: | 1467420083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8929 PARALLEL PARKWAY | ||||||||
| Address2: | PMG-PHYSICIAN CREDENTIALING ATTN KATHLEEN | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 661121689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9135963893 | ||||||||
| FaxNumber: | 7852707646 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 FIRST TERRACE | ||||||||
| Address2: | #200 | ||||||||
| City: | LANSING | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660431735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137276000 | ||||||||
| FaxNumber: | 9133511346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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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 | 363LF0000X | 53-45399-121 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.