Individual
WAYLON COLBY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRNA, CPNP-AC, CCRN
Contact information
Practice address
701 N 1ST ST, SPRINGFIELD, IL 62781-0001
(217) 788-3755
Mailing address
50 FRONTIER LAKE DR, SPRINGFIELD, IL 62707-7726
(618) 977-1719
Taxonomy
Speciality
Code
Description
License number
State
163WC0200X
Critical Care Medicine Registered Nurse
2002014595
MO
363LP0222X
Critical Care Pediatric Nurse Practitioner
20071425
MO
367500000X
Certified Registered Nurse Anesthetist
Primary
209011241
IL
Other
Enumeration date
12/06/2007
Last updated
10/31/2016
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