Polly Rebecca Jackson, AG-ACNP

Primary specialty

Acute Care Nurse PractitionerTaxonomy code 363LA2100X

License

2015041436 Issued in MO

Practice address

901 E 5TH St
Washington, MO 63090-3127

Phone

(636) 239-8231

NPI assigned

Dec 3, 2015

Last updated

Oct 25, 2022By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Nurse Practitioner

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1449100800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1666656000000",
    "number": "1790150688",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "901 E 5TH ST",
            "city": "WASHINGTON",
            "state": "MO",
            "postal_code": "630903127",
            "telephone_number": "636-239-8231"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 E 5TH ST",
            "city": "WASHINGTON",
            "state": "MO",
            "postal_code": "630903127",
            "telephone_number": "636-239-8231"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "615 S New Ballas Rd",
            "address_purpose": "LOCATION",
            "city": "Saint Louis",
            "state": "MO",
            "postal_code": "631418221",
            "country_code": "US",
            "telephone_number": "314-251-0175",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "POLLY",
        "middle_name": "REBECCA",
        "name_prefix": "Mrs.",
        "credential": "AG-ACNP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-12-03",
        "last_updated": "2022-10-25",
        "certification_date": "2022-10-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LA2100X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Acute Care",
            "state": "MO",
            "license": "2015041436",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Acute Care Nurse Practitioner in Washington, MO
• Providers in Washington, MO by specialty
• Acute Care Nurse Practitioner in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 25, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.