Provider Demographics
NPI:1811944986
Name:JACKSON, REBECCA DENISE (FNP,CNM)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP,CNM
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:DENISE
Other - Last Name:KUEHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP,CNM
Mailing Address - Street 1:1210 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-5013
Mailing Address - Country:US
Mailing Address - Phone:812-847-7005
Mailing Address - Fax:812-847-5309
Practice Address - Street 1:1210 N 1000 W
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-5013
Practice Address - Country:US
Practice Address - Phone:812-847-7005
Practice Address - Fax:812-847-5309
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001698A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner