MEDICARE: MICHAEL F JACKSON CRNA

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	367500000X	Certified Registered Nurse Anesthetist	106810	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538149265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL F JACKSON CRNA

Provider Business Mailing Address
First Line	:	PO BOX 22407
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-0407
Country	:	US
Telephone Number	:	636-386-7222
Fax Number	:	636-386-7810

Provider Business Practice Location Address
First Line	:	12639 OLD TESSON RD STE 130
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-4814
Country	:	US
Telephone Number	:	636-386-7222
Fax Number	:	636-386-7810

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	01/30/2026

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