Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LC1500X | Nurse Practitioner - Community Health | 26NJ00025500 | NJ |
Y | 363LP0200X | Nurse Practitioner - Pediatrics | TP004745D | PA |
NPI | 1801877907 |
---|---|
Provider Name | Ms. Paula Deaun Jackson |
First Address | Philadelphia, PA 19153-1913 |
Second Address | Philadelphia, PA 19134-1011 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/11/2005 |
Last Update Date | 09/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1709420 | (05) | PA |
9036407 | (05) | NJ |
S60760 | (02) |