Provider Demographics
NPI:1649727637
Name:JACKSON, NIKKITTA ANTOINETTE
Entity type:Individual
Prefix:
First Name:NIKKITTA
Middle Name:ANTOINETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19436 BURGESS
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1820
Mailing Address - Country:US
Mailing Address - Phone:734-299-0208
Mailing Address - Fax:
Practice Address - Street 1:19436 BURGESS
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1820
Practice Address - Country:US
Practice Address - Phone:734-299-0208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703117130164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse