Healthcare Provider Details

I. General information

NPI: 1548443146
Provider Name (Legal Business Name): WAYLON COLBY JACKSON CRNA, CPNP-AC, CCRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

IV. Provider business mailing address

50 FRONTIER LAKE DR
SPRINGFIELD IL
62707-7726
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3755
  • Fax:
Mailing address:
  • Phone: 618-977-1719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2002014595
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number20071425
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209011241
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: