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NPI Code Detail

MEDICARE: MICHELENE JACKSON PA

MEDICARE: MICHELENE JACKSON PA
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 AssistantPA.0000444CO

General Provider Information

NPI Number : 1679565394
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHELENE JACKSON PA
Provider Business Mailing Address
First Line : 3701 S BROADWAY
Second Line :
City : ENGLEWOOD
State : CO
Zip : 80113-3611
Country : US
Telephone Number : 303-360-6276
Fax Number :
Provider Business Practice Location Address
First Line : 3292 PEORIA ST
Second Line :
City : AURORA
State : CO
Zip : 80010-1517
Country : US
Telephone Number : 303-360-6276
Fax Number : 303-467-5355
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/18/2005
Last Update Date : 04/12/2016

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Directions to “ MICHELENE JACKSON PA” Practice Location

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