MEDICARE: AMY JACKSON

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	156F00000X	Technician/Technologist	230750	PA

General Provider Information

NPI Number	:	1679425060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY JACKSON

Provider Business Mailing Address
First Line	:	1155 HIGHWAY 315 BLVD
Second Line	:
City	:	WILKES BARRE
State	:	PA
Zip	:	18702-6928
Country	:	US
Telephone Number	:	570-235-1667
Fax Number	:	570-235-1667

Provider Business Practice Location Address
First Line	:	1155 HIGHWAY 315 BLVD
Second Line	:
City	:	WILKES BARRE
State	:	PA
Zip	:	18702-6928
Country	:	US
Telephone Number	:	570-235-1667
Fax Number	:	570-235-1667

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

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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Directions to “ AMY JACKSON ” Practice Location

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