Healthcare Provider Details

I. General information

NPI: 1871961250
Provider Name (Legal Business Name): JUDITH AMY JACKSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 25TH ST STE C
COLUMBUS IN
47201-3240
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-372-8426
  • Fax: 812-378-7777
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28173738A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: