=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497703649
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN ANN JACKSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 N GREENE ST
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-605-7000
-----------------------------------------------------
Fax | 410-605-7912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 FOX HILL CT
-----------------------------------------------------
City | PERRY HALL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21128-9731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-605-7000
-----------------------------------------------------
Fax | 410-605-7912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | R0555083
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------