Provider Demographics
NPI:1063582864
Name:JACKSON, CAROL BOWSER (RN)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:BOWSER
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 TERENCE DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3742
Mailing Address - Country:US
Mailing Address - Phone:301-856-5259
Mailing Address - Fax:
Practice Address - Street 1:9501 FARRELL RD
Practice Address - Street 2:BLDG 815,RM 139
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5901
Practice Address - Country:US
Practice Address - Phone:703-805-0498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR103314163WX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0106XNursing Service ProvidersRegistered NurseOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR103314OtherNURSING