Provider Demographics
NPI:1558956235
Name:JACKSON, TRICIA MARIE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8124 VETERANS HWY
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1412
Mailing Address - Country:US
Mailing Address - Phone:410-987-5244
Mailing Address - Fax:
Practice Address - Street 1:8124 VETERANS HWY
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1412
Practice Address - Country:US
Practice Address - Phone:410-987-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214869363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily