1801877907 NPI number — PAULA DEAUN JACKSON CRNP

Table of content: ROSHANA SEMPLE (NPI 1467169144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801877907 NPI number — PAULA DEAUN JACKSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
PAULA
Provider Middle Name:
DEAUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
PAULA
Provider Other Middle Name:
DEAUN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PMHNP, CRNP, LNC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1801877907
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
READING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19612-3579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
484-628-1324
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
160 E ERIE AVE
Provider Second Line Business Practice Location Address:
SUITE 3311
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19134-1011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-427-3871
Provider Business Practice Location Address Fax Number:
215-492-8119
Provider Enumeration Date:
11/07/2005

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: 363LC1500X , with the licence number:  26NJ00025500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: TP004745D , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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