Provider Demographics
NPI:1144318296
Name:JACKSON, KATRINA A (CRNA)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S. UNIVERSITY
Mailing Address - Street 2:SUITE 505
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5307
Mailing Address - Country:US
Mailing Address - Phone:501-664-4532
Mailing Address - Fax:501-663-4335
Practice Address - Street 1:500 S. UNIVERSITY
Practice Address - Street 2:SUITE 505
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5307
Practice Address - Country:US
Practice Address - Phone:501-664-4532
Practice Address - Fax:501-663-4335
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC00815207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5S440OtherAR BLUE CROSS BLUE SHIELD
AR5S440OtherAR BLUE CROSS BLUE SHIELD
AR5S440Medicare PIN