Provider Demographics
NPI:1639461734
Name:EDWARDS-JACKSON, NNEKA SAFIYA (MD)
Entity Type:Individual
Prefix:
First Name:NNEKA
Middle Name:SAFIYA
Last Name:EDWARDS-JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 E THOMAS RD STE 130
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-0008
Mailing Address - Country:US
Mailing Address - Phone:323-361-3550
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-07
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA124478208000000X
AZ65492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty