Provider Demographics
NPI:1922561653
Name:JACKSON, AMANDA J (APRN)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:025-889-4905
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2811 HOLMANS LN
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5915
Practice Address - Country:US
Practice Address - Phone:502-446-5555
Practice Address - Fax:502-394-3674
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009089A363LF0000X
KY3013285363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100604600Medicaid
IN300027709Medicaid