Healthcare Provider Details

I. General information

NPI: 1497703649
Provider Name (Legal Business Name): KAREN ANN JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N GREENE ST
BALTIMORE MD
21201-1524
US

IV. Provider business mailing address

10 FOX HILL CT
PERRY HALL MD
21128-9731
US

V. Phone/Fax

Practice location:
  • Phone: 410-605-7000
  • Fax: 410-605-7912
Mailing address:
  • Phone: 410-605-7000
  • Fax: 410-605-7912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0555083
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: