Provider Demographics
NPI:1902416795
Name:JACKSON, LONDON TERI (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LONDON
Middle Name:TERI
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:LONDON
Other - Middle Name:TERI
Other - Last Name:ROBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-2252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-2252
Practice Address - Country:US
Practice Address - Phone:801-491-2238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8735023-4405363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care