Provider Demographics
NPI:1902906548
Name:JACKSON, LINDA D (RN,MSN,NP-C)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN,MSN,NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 S CALAVERAS DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-1942
Mailing Address - Country:US
Mailing Address - Phone:719-564-0450
Mailing Address - Fax:719-564-1659
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE A 535
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-0450
Practice Address - Fax:719-564-1659
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO76267363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38330750Medicaid
COC365208Medicare PIN
CO38330750Medicaid