Provider Demographics
NPI:1013685957
Name:JACKSON, MYRVIENNE (FNP)
Entity Type:Individual
Prefix:
First Name:MYRVIENNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MYRVIENNE
Other - Middle Name:
Other - Last Name:LEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1116 SYCAMORE LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129-4364
Mailing Address - Country:US
Mailing Address - Phone:347-479-0478
Mailing Address - Fax:
Practice Address - Street 1:514 BRANDIES CIR STE A
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-7751
Practice Address - Country:US
Practice Address - Phone:615-849-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2021101282363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily