MEDICARE: KARLA JACKSON ACNPC-AG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	904658	MS

General Provider Information

NPI Number	:	1235707837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARLA JACKSON ACNPC-AG

Provider Business Mailing Address
First Line	:	PO BOX 634
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38835-0634
Country	:	US
Telephone Number	:	662-416-8827
Fax Number	:

Provider Business Practice Location Address
First Line	:	3196 HIGHWAY 72 W
Second Line	:
City	:	CORINTH
State	:	MS
Zip	:	38834-9303
Country	:	US
Telephone Number	:	662-284-9541
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2021
Last Update Date	:	06/11/2021

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