Provider Demographics
NPI:1023103397
Name:JACKSON, PENNI F (PAC)
Entity type:Individual
Prefix:MRS
First Name:PENNI
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:PENNI
Other - Middle Name:F
Other - Last Name:HORWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4445 S 86TH ST # 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9225
Mailing Address - Country:US
Mailing Address - Phone:402-414-4200
Mailing Address - Fax:402-414-4202
Practice Address - Street 1:6940 VAN DORN ST STE 201
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2858
Practice Address - Country:US
Practice Address - Phone:402-413-6363
Practice Address - Fax:402-512-9133
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1137363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE277287Medicare PIN
Q10296Medicare UPIN
NENA1080048Medicare PIN
NEP00166586Medicare PIN
NENA1079048Medicare PIN