Provider Demographics
NPI:1932656931
Name:NISHA JACKSON INC.
Entity Type:Organization
Organization Name:NISHA JACKSON INC.
Other - Org Name:PEAK MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:STULTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-210-8721
Mailing Address - Street 1:3236 HILLCREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2423 NW TROOST ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1706
Practice Address - Country:US
Practice Address - Phone:541-464-0788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086006299N7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR184844Medicare PIN