1073619037 NPI number — KATHLEEN J. JACKSON RN-APN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073619037 NPI number — KATHLEEN J. JACKSON RN-APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
KATHLEEN
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN-APN
Provider Gender Code:
F

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:
1073619037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
602 WCUTHBERT BLVD UNIT 26 STE A
Provider Second Line Business Mailing Address:
UNIT 26, SUITE A
Provider Business Mailing Address City Name:
WESTMONT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08108-4197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-946-5180
Provider Business Mailing Address Fax Number:
856-946-5181

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 W CUTHBERT BLVD UNIT 26
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HADDON TOWNSHIP
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08108-3642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-946-5180
Provider Business Practice Location Address Fax Number:
856-946-5181
Provider Enumeration Date:
09/16/2006

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: 363L00000X , with the licence number:  TP001754C , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 26NN06425500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 26NN06425500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8780803 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: P3845837/2854869 . This is a "OXFORD/UNITED HLTH." identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 9765851 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60037187 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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