Provider Demographics
NPI:1013099795
Name:JACKSON, JOANNE (NP)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:M
Other - Last Name:CADIEUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FL
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1001
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:413-794-1629
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:2ND FLOOR, SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1112
Practice Address - Country:US
Practice Address - Phone:413-794-2273
Practice Address - Fax:413-794-0198
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA141500363L00000X, 363LF0000X
MARN141500363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily