Healthcare Provider Details

I. General information

NPI: 1639033525
Provider Name (Legal Business Name): MIESHA ANTOINETTE JACKSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7990 E US HIGHWAY 36
AVON IN
46123-7790
US

IV. Provider business mailing address

6139 MUNSEE LN
INDIANAPOLIS IN
46228-1332
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 317-533-9396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017536A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: