Provider Demographics
NPI:1407244452
Name:JACKSON, JOHNNIE (RN)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7847
Mailing Address - Country:US
Mailing Address - Phone:601-497-1306
Mailing Address - Fax:601-366-5949
Practice Address - Street 1:1901 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7847
Practice Address - Country:US
Practice Address - Phone:601-497-1306
Practice Address - Fax:601-366-5949
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-29
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR127260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily