Healthcare Provider Details

I. General information

NPI: 1831165166
Provider Name (Legal Business Name): CHERYL ANNE JACKSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SHICKSHINNEY LAKE ROAD
HUNTINGTON MILLS PA
18622-0046
US

IV. Provider business mailing address

16 HIGHLAND CT
DALLAS PA
18612-1237
US

V. Phone/Fax

Practice location:
  • Phone: 570-864-3191
  • Fax: 570-864-2569
Mailing address:
  • Phone: 570-674-2268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberVP005790B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: