Healthcare Provider Details

I. General information

NPI: 1447062211
Provider Name (Legal Business Name): KELI NALU PATRICIA JACKSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6746 S REVERE PKWY STE 180
CENTENNIAL CO
80112-6763
US

IV. Provider business mailing address

6746 S REVERE PKWY STE 180
CENTENNIAL CO
80112-6763
US

V. Phone/Fax

Practice location:
  • Phone: 303-632-3640
  • Fax: 303-632-3642
Mailing address:
  • Phone: 303-632-3640
  • Fax: 303-632-3642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0008946
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: