Provider Demographics
NPI:1952326266
Name:JACKSON, NISHA MARIE (MS, WHCNP)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MS, WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 STATE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8450
Mailing Address - Country:US
Mailing Address - Phone:541-773-9772
Mailing Address - Fax:541-773-1113
Practice Address - Street 1:3156 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR86006299207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012158Medicaid
OR012158Medicaid