Provider Demographics
NPI:1447658919
Name:JACKSON, AMANDA R (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
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 1:1101 E STONE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3384
Mailing Address - Country:US
Mailing Address - Phone:423-224-1110
Mailing Address - Fax:423-224-1130
Practice Address - Street 1:111 W STONE DR STE 110
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-6027
Practice Address - Country:US
Practice Address - Phone:423-224-3701
Practice Address - Fax:423-224-3709
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN182185163W00000X
TN19521363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1447658919Medicaid
TNQ010785Medicaid
TN10350I2753Medicare PIN
VAVVL622AMedicare PIN
TNQ010785Medicaid