Provider Demographics
NPI:1528249638
Name:JACKSON, KATHERINE (FNP)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5810 OBATA WAY
Mailing Address - Street 2:SUITE #1
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-7039
Mailing Address - Country:US
Mailing Address - Phone:408-592-8371
Mailing Address - Fax:
Practice Address - Street 1:5810 OBATA WAY
Practice Address - Street 2:SUITE #1
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-7039
Practice Address - Country:US
Practice Address - Phone:408-592-8371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily