Provider Demographics
NPI:1932676194
Name:JACKSON, ELLANIKOLE (DNP)
Entity Type:Individual
Prefix:DR
First Name:ELLANIKOLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RECREATION LN
Mailing Address - Street 2:
Mailing Address - City:COUNCE
Mailing Address - State:TN
Mailing Address - Zip Code:38326-3496
Mailing Address - Country:US
Mailing Address - Phone:901-500-8629
Mailing Address - Fax:
Practice Address - Street 1:11268 HIGHWAY 57
Practice Address - Street 2:
Practice Address - City:COUNCE
Practice Address - State:TN
Practice Address - Zip Code:38326-3802
Practice Address - Country:US
Practice Address - Phone:731-438-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24869363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily