Provider Demographics
NPI:1376557702
Name:JACKSON, PATRICIA L (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:TRETHEWEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:230 CATALPA
Mailing Address - Street 2:SUITE D
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:574-257-7551
Mailing Address - Fax:574-257-7535
Practice Address - Street 1:230 W CATALPA DR
Practice Address - Street 2:SUITE D
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8321
Practice Address - Country:US
Practice Address - Phone:574-257-7551
Practice Address - Fax:574-257-7535
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001911A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200519100Medicaid
IN200519100Medicaid
INQ44840Medicare UPIN