Provider Demographics
NPI:1609313840
Name:JACKSON, LAKESHIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LAKESHIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 NORTHWEST DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2334
Mailing Address - Country:US
Mailing Address - Phone:989-274-7886
Mailing Address - Fax:
Practice Address - Street 1:912 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-2564
Practice Address - Country:US
Practice Address - Phone:989-791-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295598363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner