Provider Demographics
NPI:1548443146
Name:JACKSON, WAYLON COLBY (CRNA, CPNP-AC, CCRN)
Entity type:Individual
Prefix:
First Name:WAYLON
Middle Name:COLBY
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA, CPNP-AC, CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 FRONTIER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62707-7726
Mailing Address - Country:US
Mailing Address - Phone:618-977-1719
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-0001
Practice Address - Country:US
Practice Address - Phone:217-788-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014595163WC0200X
MO20071425363LP0222X
IL209011241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care