Provider Demographics
NPI:1366539637
Name:JACKSON, KRYSTAL M (PAC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:NE
Mailing Address - Zip Code:68405-9319
Mailing Address - Country:US
Mailing Address - Phone:620-253-4771
Mailing Address - Fax:
Practice Address - Street 1:8550 CUTHILLS CIR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68526-9474
Practice Address - Country:US
Practice Address - Phone:024-476-6060
Practice Address - Fax:402-476-6809
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1549363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
426877Medicare ID - Type UnspecifiedFOWLER CLINIC
426876Medicare ID - Type UnspecifiedMINNEOLA CLINIC
KS200360100BMedicaid
Q49424Medicare UPIN
KS200360100AMedicaid