Basic Information
| Provider Information | |||||||||
| NPI: | 1457426942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR BLDG 7505 | ||||||||
| Address2: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267000 | ||||||||
| FaxNumber: | 7195267732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIR BLDG 7505 | ||||||||
| Address2: | EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267000 | ||||||||
| FaxNumber: | 7195267732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 09/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.