Provider Demographics
NPI:1053983734
Name:JACKSON, ALLIE (NP)
Entity type:Individual
Prefix:
First Name:ALLIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 E BRADFORD PKWY STE 105
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6512
Mailing Address - Country:US
Mailing Address - Phone:417-881-4994
Mailing Address - Fax:
Practice Address - Street 1:1435 E BRADFORD PKWY STE 105
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6512
Practice Address - Country:US
Practice Address - Phone:417-881-4994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF06211962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily