Provider Demographics
NPI:1295811511
Name:JACKSON, EILEEN (ACNP-BC, CRNFA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACNP-BC, CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32500
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-2500
Mailing Address - Country:US
Mailing Address - Phone:520-444-8940
Mailing Address - Fax:520-760-6690
Practice Address - Street 1:11957 E SUMMER TRL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85749-9313
Practice Address - Country:US
Practice Address - Phone:520-444-8940
Practice Address - Fax:520-760-6690
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN-075070163WR0006X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ918849OtherAHCCCS