Provider Demographics
NPI:1225628993
Name:JACKSON, NICKOLAS NATHANIEL (FNP, RN)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:NATHANIEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13471 BEDELL ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4551
Mailing Address - Country:US
Mailing Address - Phone:347-759-9040
Mailing Address - Fax:
Practice Address - Street 1:13471 BEDELL ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-4551
Practice Address - Country:US
Practice Address - Phone:347-759-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily