Healthcare Provider Details

I. General information

NPI: 1710364211
Provider Name (Legal Business Name): NICOLE M. JACKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HARTFORD RD
MANCHESTER CT
06040-5921
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119-3791
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-4673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number66831
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number274945
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: