Provider Demographics
NPI:1285457770
Name:JACKSON, AMANDA (RN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:300 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ELLINWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:67526-1452
Mailing Address - Country:US
Mailing Address - Phone:620-566-1730
Mailing Address - Fax:620-564-2105
Practice Address - Street 1:300 N PARK AVE
Practice Address - Street 2:
Practice Address - City:ELLINWOOD
Practice Address - State:KS
Practice Address - Zip Code:67526-1452
Practice Address - Country:US
Practice Address - Phone:620-566-1730
Practice Address - Fax:620-564-2105
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-132083-062163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency