Provider Demographics
NPI:1194136010
Name:JACKSON, LUKE JARVIS (CRNA)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:JARVIS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:543 W 2700 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-3004
Mailing Address - Country:US
Mailing Address - Phone:435-531-9643
Mailing Address - Fax:
Practice Address - Street 1:1400 29TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5353
Practice Address - Country:US
Practice Address - Phone:409-454-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-RN-LIC-74240367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered