Provider Demographics
NPI:1518781848
Name:JACKSON, MERCEDES DENISE (LPN, CPST)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN, CPST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12961 DUNSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-4702
Mailing Address - Country:US
Mailing Address - Phone:314-479-8661
Mailing Address - Fax:
Practice Address - Street 1:12961 DUNSTONE DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-4702
Practice Address - Country:US
Practice Address - Phone:314-479-8661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043125373164W00000X
171400000X, 171M00000X, 174H00000X
MO2010039936164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness Coach
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth Educator