Healthcare Provider Details

I. General information

NPI: 1073525150
Provider Name (Legal Business Name): PATRICIA L JACKSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 N 22ND ST UNIT A
LARAMIE WY
82072-5306
US

IV. Provider business mailing address

1252 N 22ND ST UNIT A
LARAMIE WY
82072-5306
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5364
  • Fax: 307-745-4164
Mailing address:
  • Phone: 307-745-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number43087
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4708
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: