Provider Demographics
NPI:1649602905
Name:JACKSON, HEATHER ELIZABETH (ACNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELIZABETH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6286 PEPPER HILL ST
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2301
Mailing Address - Country:US
Mailing Address - Phone:313-400-8007
Mailing Address - Fax:
Practice Address - Street 1:6286 PEPPER HILL ST
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2301
Practice Address - Country:US
Practice Address - Phone:313-400-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704214316363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care