Provider Demographics
NPI:1659835411
Name:JACKSON, DONNA J
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:JACKSON
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 1:118 E ROBERTSON RD
Mailing Address - Street 2:
Mailing Address - City:CASTALIAN SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:37031-4610
Mailing Address - Country:US
Mailing Address - Phone:317-407-7302
Mailing Address - Fax:
Practice Address - Street 1:118 E ROBERTSON RD
Practice Address - Street 2:
Practice Address - City:CASTALIAN SPRINGS
Practice Address - State:TN
Practice Address - Zip Code:37031-4610
Practice Address - Country:US
Practice Address - Phone:317-407-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000177401163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse