MEDICARE: GARTH JACKSON AGACNP-BC

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
1	363LA2100X	Acute Care Nurse Practitioner	26NJ01474100	NJ

General Provider Information

NPI Number	:	1467146878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARTH JACKSON AGACNP-BC

Provider Business Mailing Address
First Line	:	79 SPINYTHORN RD
Second Line	:
City	:	LEVITTOWN
State	:	PA
Zip	:	19056-2216
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 SPINYTHORN RD
Second Line	:
City	:	LEVITTOWN
State	:	PA
Zip	:	19056-2216
Country	:	US
Telephone Number	:	215-783-8014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	06/07/2023

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