Provider Demographics
NPI:1548099757
Name:JACKSON, KATRINA MARCIA (CNM)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:MARCIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4204
Mailing Address - Country:US
Mailing Address - Phone:405-464-8126
Mailing Address - Fax:
Practice Address - Street 1:3 SHAWS CV STE 206
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4968
Practice Address - Country:US
Practice Address - Phone:860-443-4148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT576367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT576OtherCONNECTICUT STATE NURSE MIDWIFE LICENSE