Healthcare Provider Details

I. General information

NPI: 1740835966
Provider Name (Legal Business Name): ANASTASIA JACKSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MERCY WAY
JOPLIN MO
64804-4524
US

IV. Provider business mailing address

5833 S 79TH EAST AVE
TULSA OK
74145-8656
US

V. Phone/Fax

Practice location:
  • Phone: 417-781-2727
  • Fax:
Mailing address:
  • Phone: 310-795-3752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024043054
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number943949
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberM135050
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: