Provider Demographics
NPI:1831176239
Name:JACKSON, HEIDI LYNN (CPNP)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 PINEY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-2101
Mailing Address - Country:US
Mailing Address - Phone:410-287-3417
Mailing Address - Fax:
Practice Address - Street 1:USAMEDDAC
Practice Address - Street 2:2480 LLEWELLYN AVE
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755
Practice Address - Country:US
Practice Address - Phone:410-287-3417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR070129363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics