Provider Demographics
NPI:1356906887
Name:JACKSON, MARILYN K (RN)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:K
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 HOOWAIWAI LOOP APT 2801
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-4134
Mailing Address - Country:US
Mailing Address - Phone:808-250-6543
Mailing Address - Fax:
Practice Address - Street 1:335 S PAPA AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1528
Practice Address - Country:US
Practice Address - Phone:808-944-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI72652163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical