Provider Demographics
NPI:1508942954
Name:JACKSON, HEIDI A (ARNP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 N MAIN ST
Mailing Address - Street 2:PO BOX 299
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-1133
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1510
Practice Address - Street 1:261 N ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2616
Practice Address - Country:US
Practice Address - Phone:480-305-2888
Practice Address - Fax:480-305-2889
Is Sole Proprietor?:No
Enumeration Date:2006-10-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
510793OtherRN
MJ0564117OtherDEA
510793OtherRN