Basic Information
Provider Information | |||||||||
NPI: | 1811944986 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP,CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KUEHN | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: | DENISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP,CNM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1210 N 1000 W | ||||||||
Address2: |   | ||||||||
City: | LINTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474415013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128477005 | ||||||||
FaxNumber: | 8128475309 | ||||||||
Practice Location | |||||||||
Address1: | 1210 N 1000 W | ||||||||
Address2: |   | ||||||||
City: | LINTON | ||||||||
State: | IN | ||||||||
PostalCode: | 474415013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8128477005 | ||||||||
FaxNumber: | 8128475309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/27/2006 | ||||||||
LastUpdateDate: | 02/24/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71001698A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.