Provider Demographics
NPI:1770228280
Name:JACKSON, RENA ROSETT (RN)
Entity type:Individual
Prefix:MRS
First Name:RENA
Middle Name:ROSETT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:RENA
Other - Middle Name:ROSETT
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6139
Mailing Address - Country:US
Mailing Address - Phone:601-456-9799
Mailing Address - Fax:
Practice Address - Street 1:100 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-6139
Practice Address - Country:US
Practice Address - Phone:601-456-9799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS893821163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health