Provider Demographics
NPI:1942758032
Name:JACKSON, URSULA L (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:URSULA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:URSULA
Other - Middle Name:L
Other - Last Name:TELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13944 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-3804
Mailing Address - Country:US
Mailing Address - Phone:216-767-4274
Mailing Address - Fax:
Practice Address - Street 1:13944 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-3804
Practice Address - Country:US
Practice Address - Phone:216-767-4274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-16
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP-019895363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily