Healthcare Provider Details

I. General information

NPI: 1073619037
Provider Name (Legal Business Name): KATHLEEN J. JACKSON RN-APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 MAESTAS RD
TAOS NM
87571-6268
US

IV. Provider business mailing address

602 WCUTHBERT BLVD UNIT 26 STE A UNIT 26, SUITE A
WESTMONT NJ
08108-4197
US

V. Phone/Fax

Practice location:
  • Phone: 575-776-7806
  • Fax: 575-224-3348
Mailing address:
  • Phone: 856-946-5180
  • Fax: 856-946-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NN06425500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NN06425500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP001754C
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: