Provider Demographics
NPI:1508288762
Name:JACKSON, NICOLE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:S
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9146 E STOCKTON BLVD UNIT 1070
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9510
Mailing Address - Country:US
Mailing Address - Phone:916-873-0976
Mailing Address - Fax:
Practice Address - Street 1:7001A EAST PKWY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2501
Practice Address - Country:US
Practice Address - Phone:916-873-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker