Provider Demographics
NPI:1528576618
Name:JACKOWSKI, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JACKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 OLD NATIONAL PIKE ROAD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:724-632-6312
Practice Address - Street 1:100 WILSON ROAD
Practice Address - Street 2:
Practice Address - City:BENTLEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:15314-1028
Practice Address - Country:US
Practice Address - Phone:724-239-2390
Practice Address - Fax:724-239-2393
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018536208D00000X, 363LP2300X, 363LS0200X, 363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health