Provider Demographics
NPI:1346211273
Name:JACKSON, DARRYE (ARNP)
Entity type:Individual
Prefix:
First Name:DARRYE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2543
Mailing Address - Fax:870-301-2092
Practice Address - Street 1:312 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2428
Practice Address - Country:US
Practice Address - Phone:270-753-2395
Practice Address - Fax:270-759-4745
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3315P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005923Medicaid
KY78005923Medicaid
KYP34555Medicare UPIN
KYK026710Medicare PIN