Provider Demographics
NPI:1821055880
Name:JACKSON, JUDITH (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
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 1:6341 26TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-3505
Mailing Address - Country:US
Mailing Address - Phone:651-779-0954
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1395
Practice Address - Country:US
Practice Address - Phone:612-672-2288
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1144729363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner