Provider Demographics
NPI:1720206162
Name:JACKSON, NANCY LOUISE (RN)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LOUISE
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 1:9408 VAN ANTWERP RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-6245
Mailing Address - Country:US
Mailing Address - Phone:810-231-0207
Mailing Address - Fax:801-231-1693
Practice Address - Street 1:9408 VAN ANTWERP RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-6245
Practice Address - Country:US
Practice Address - Phone:810-231-0207
Practice Address - Fax:801-231-1693
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704159337163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management