Provider Demographics
NPI:1861634552
Name:JACKSON, MARISSA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
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 1:2883 MOUNTAIN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-7517
Mailing Address - Country:US
Mailing Address - Phone:520-803-9926
Mailing Address - Fax:
Practice Address - Street 1:101 N CORONADO DR
Practice Address - Street 2:SUITE A
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6358
Practice Address - Country:US
Practice Address - Phone:520-792-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN100325163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult