Healthcare Provider Details

I. General information

NPI: 1306372842
Provider Name (Legal Business Name): TERESA LYNNE JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 10/04/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 N SUMMIT ST
ARKANSAS CITY KS
67005-2258
US

IV. Provider business mailing address

118 N SUMMIT ST
ARKANSAS CITY KS
67005-2258
US

V. Phone/Fax

Practice location:
  • Phone: 620-506-5005
  • Fax: 620-506-5002
Mailing address:
  • Phone: 620-660-2105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5377626021
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: