Provider Demographics
NPI:1447888243
Name:JACKSON, MIRANDA (CRNA)
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11583 E 118TH PL
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80640-7419
Mailing Address - Country:US
Mailing Address - Phone:303-522-2941
Mailing Address - Fax:
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-810-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9509988163W00000X
FLAPRN11032969367500000X
CO138117367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse