Provider Demographics
NPI:1740906072
Name:JACKSON, NATALIE JANEL
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:JANEL
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 1:14044 W CAMELBACK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9426
Mailing Address - Country:US
Mailing Address - Phone:623-935-9600
Mailing Address - Fax:
Practice Address - Street 1:14044 W CAMELBACK RD STE 204
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9426
Practice Address - Country:US
Practice Address - Phone:623-935-9600
Practice Address - Fax:623-935-9602
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN140246163W00000X
AZ295795363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse