Basic Information
| Provider Information | |||||||||
| NPI: | 1952403065 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | BECKY | ||||||||
| MiddleName: | DIXON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE ANESTHETIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7397 | ||||||||
| Address2: | |||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298047397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 UNIVERSITY PKWY | ||||||||
| Address2: | ANESTHESIA DEPARTMENT | ||||||||
| City: | AIKEN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 298016302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365531659 | ||||||||
| FaxNumber: | 3365533994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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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 | 367500000X | 2782 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN0576 | 05 | SC | MEDICAID |