Provider Demographics
NPI:1487543351
Name:JACKSON, TARYN (PA-C)
Entity type:Individual
Prefix:
First Name:TARYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-2517
Mailing Address - Country:US
Mailing Address - Phone:970-630-2236
Mailing Address - Fax:
Practice Address - Street 1:825 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-9400
Practice Address - Country:US
Practice Address - Phone:308-432-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant