Provider Demographics
NPI:1053696971
Name:JACKSON, CARLY ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANNE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:BOX 78534
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278
Mailing Address - Country:US
Mailing Address - Phone:815-398-9491
Mailing Address - Fax:815-381-7333
Practice Address - Street 1:324 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5090
Practice Address - Country:US
Practice Address - Phone:815-398-9491
Practice Address - Fax:815-381-7333
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2014-06-05
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant