Provider Demographics
NPI:1053300855
Name:JACKSON, PATRICIA A (RN, MSN, PPCNP-BC, P)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, MSN, PPCNP-BC, P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 LITTLETON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-3198
Mailing Address - Country:US
Mailing Address - Phone:978-577-0437
Mailing Address - Fax:
Practice Address - Street 1:133 LITTLETON RD STE 101
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3198
Practice Address - Country:US
Practice Address - Phone:978-577-0437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229632363LP0200X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA020860Medicaid