Provider Demographics
NPI:1093285496
Name:JACKSON, CHRISTOPHER M (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:M
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 PINE ST
Mailing Address - Street 2:
Mailing Address - City:CORUNNA
Mailing Address - State:MI
Mailing Address - Zip Code:48817-1031
Mailing Address - Country:US
Mailing Address - Phone:810-449-0566
Mailing Address - Fax:
Practice Address - Street 1:302 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2044
Practice Address - Country:US
Practice Address - Phone:810-762-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704247130363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty