Provider Demographics
NPI:1184407801
Name:JACKSON, SHERIEFFA NICOLA (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHERIEFFA
Middle Name:NICOLA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2389 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-4617
Mailing Address - Country:US
Mailing Address - Phone:860-467-1907
Mailing Address - Fax:860-718-9509
Practice Address - Street 1:2389 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-4617
Practice Address - Country:US
Practice Address - Phone:860-790-9428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12246363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty