Provider Demographics
NPI:1396717286
Name:JACKSON, SANDRA F (CRNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:F
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W 37TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802-2225
Mailing Address - Country:US
Mailing Address - Phone:302-450-4551
Mailing Address - Fax:302-355-2550
Practice Address - Street 1:23 W 37TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802-2225
Practice Address - Country:US
Practice Address - Phone:302-450-4551
Practice Address - Fax:302-355-2550
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG-0000519363LF0000X
PASP008227363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1396717286 363L00000Medicaid