Provider Demographics
NPI:1497718811
Name:JACKSON, ANITRA L (NP)
Entity Type:Individual
Prefix:MS
First Name:ANITRA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2383
Mailing Address - Country:US
Mailing Address - Phone:952-843-4333
Mailing Address - Fax:952-843-4301
Practice Address - Street 1:310 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2393
Practice Address - Country:US
Practice Address - Phone:952-843-4333
Practice Address - Fax:952-843-4301
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1308387163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical