1063466951 NPI number — CHRISTIAN JACKSON CRNA

Table of content: CHRISTIAN JACKSON CRNA (NPI 1063466951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063466951 NPI number — CHRISTIAN JACKSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CHRISTIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063466951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8717 W 110TH ST
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66210-2144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-428-2900
Provider Business Mailing Address Fax Number:
913-428-2951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19600 E 39TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64057-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-428-2900
Provider Business Practice Location Address Fax Number:
913-428-2951
Provider Enumeration Date:
05/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  2001004399 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)