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NPI Code Detail

MEDICARE: KRYSTAL M JACKSON PAC

MEDICARE: KRYSTAL M JACKSON PAC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant1549NE
2363A00000XPhysician Assistant

General Provider Information

NPI Number : 1366539637
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL M JACKSON PAC
Provider Business Mailing Address
First Line : 812 3RD ST
Second Line :
City : MILFORD
State : NE
Zip : 68405-9319
Country : US
Telephone Number : 620-253-4771
Fax Number :
Provider Business Practice Location Address
First Line : 8550 CUTHILLS CIR
Second Line :
City : LINCOLN
State : NE
Zip : 68526-9474
Country : US
Telephone Number : 24-476-6060
Fax Number : 402-476-6809
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/06/2006
Last Update Date : 10/31/2024

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Directions to “ KRYSTAL M JACKSON PAC” Practice Location

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