Provider Demographics
NPI:1053419606
Name:JACKSON, PAMELA KAROL (CFNP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:KAROL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:PAMELA
Other - Middle Name:KAROL
Other - Last Name:PLATTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:1000 S BECKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1908
Mailing Address - Country:US
Mailing Address - Phone:903-595-6680
Mailing Address - Fax:903-592-1934
Practice Address - Street 1:1000 S BECKHAM AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1908
Practice Address - Country:US
Practice Address - Phone:903-595-6680
Practice Address - Fax:903-592-1934
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX530242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX500026894OtherRAILROAD MEDICARE
TX89N835OtherBLUECROSS BLUE SHIELD TX
TX141129002Medicaid
TX89N835OtherBLUECROSS BLUE SHIELD TX
TX8456B8Medicare ID - Type Unspecified