Provider Demographics
NPI:1811212467
Name:JACKSON, FERN SCOTT (RN NP)
Entity Type:Individual
Prefix:MRS
First Name:FERN
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CAPTAIN DR APT E252
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1744
Mailing Address - Country:US
Mailing Address - Phone:510-350-7328
Mailing Address - Fax:
Practice Address - Street 1:8 CAPTAIN DR APT E252
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1744
Practice Address - Country:US
Practice Address - Phone:510-350-7328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-06
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN261555363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology