Provider Demographics
NPI:1164055109
Name:JACKSON, KARISSA KEAGAN (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:KEAGAN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:KARISSA
Other - Middle Name:KEAGAN
Other - Last Name:JUNGERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1776 PARK AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-5148
Mailing Address - Country:US
Mailing Address - Phone:385-464-3980
Mailing Address - Fax:385-464-3990
Practice Address - Street 1:1776 PARK AVE STE 211
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-5148
Practice Address - Country:US
Practice Address - Phone:385-464-3980
Practice Address - Fax:385-464-3990
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7120828-4405363LA2100X
UT71208283102163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care