Provider Demographics
NPI:1255679940
Name:JACKSON, NICOLE R (CNP, ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:R
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNP, ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E APPLE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-4200
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-4200
Practice Address - Fax:937-223-9811
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13850.NP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH171112Medicare PIN