Healthcare Provider Details

I. General information

NPI: 1295811511
Provider Name (Legal Business Name): EILEEN JACKSON ACNP-BC, CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2006
Last Update Date: 12/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11957 E SUMMER TRL
TUCSON AZ
85749-9313
US

IV. Provider business mailing address

PO BOX 32500
TUCSON AZ
85751-2500
US

V. Phone/Fax

Practice location:
  • Phone: 520-444-8940
  • Fax: 520-760-6690
Mailing address:
  • Phone: 520-444-8940
  • Fax: 520-760-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN-075070
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN-075070
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: