Provider Demographics
NPI:1386005460
Name:JACKSON, INAISHA MARIE (APN)
Entity Type:Individual
Prefix:
First Name:INAISHA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:INAISHA
Other - Middle Name:M
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:5450 WISSAHICKON AVE APT A1103
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-5261
Mailing Address - Country:US
Mailing Address - Phone:862-520-9487
Mailing Address - Fax:
Practice Address - Street 1:RUTGERS, UNIVERSITY BEHAVIORAL HEALTH CARE
Practice Address - Street 2:BATES BUILDING, 2ND FLOOR
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08625863
Practice Address - Country:US
Practice Address - Phone:609-292-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00625000363LP2300X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology