Provider Demographics
NPI:1336293323
Name:JACKSON, SHERYL JANE (CNP)
Entity Type:Individual
Prefix:
First Name:SHERYL
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 SAINT ANNE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4694
Mailing Address - Country:US
Mailing Address - Phone:605-348-8000
Mailing Address - Fax:605-348-4315
Practice Address - Street 1:636 SAINT ANNE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4694
Practice Address - Country:US
Practice Address - Phone:605-348-8000
Practice Address - Fax:605-348-4315
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0244363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
500006983Medicare PIN
SDS55816Medicare UPIN
S5544Medicare PIN