Healthcare Provider Details

I. General information

NPI: 1447060702
Provider Name (Legal Business Name): CLANTRELLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 S BLACKHAWK ST STE 240
AURORA CO
80014-1475
US

IV. Provider business mailing address

2101 S BLACKHAWK ST STE 240
AURORA CO
80014-1475
US

V. Phone/Fax

Practice location:
  • Phone: 501-613-7863
  • Fax: 580-297-9105
Mailing address:
  • Phone: 501-613-7863
  • Fax: 580-297-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN11035553
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: