Healthcare Provider Details

I. General information

NPI: 1558256214
Provider Name (Legal Business Name): NICOLE JACKSON RNCLINICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20020-5732
US

IV. Provider business mailing address

2124 MARTIN LUTHER KING JR AVE SE
WASHINGTON DC
20020-5732
US

V. Phone/Fax

Practice location:
  • Phone: 817-217-9825
  • Fax:
Mailing address:
  • Phone: 817-217-9825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number500020205
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number500020205
License Number StateDC
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number500020205
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: