Provider Demographics
NPI:1871041657
Name:JACKSON, SIMONE D (ANP)
Entity Type:Individual
Prefix:MS
First Name:SIMONE
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 BLAIR MILL RD
Mailing Address - Street 2:
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-2223
Mailing Address - Country:US
Mailing Address - Phone:267-908-2465
Mailing Address - Fax:877-383-8544
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:215-902-9014
Practice Address - Fax:877-383-8544
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162091363LA2200X
PASP019087363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health