Provider Demographics
NPI:1184988438
Name:JACKSON, NICHOLE ROSE (NP-C)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ROSE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:530 3RD ST E
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-2711
Mailing Address - Country:US
Mailing Address - Phone:701-205-3088
Mailing Address - Fax:701-335-7808
Practice Address - Street 1:3175 SIENNA DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8910
Practice Address - Country:US
Practice Address - Phone:701-205-3088
Practice Address - Fax:701-335-7808
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR31008363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND717961Medicare PIN
ND84160Medicaid