Healthcare Provider Details

I. General information

NPI: 1386315455
Provider Name (Legal Business Name): JULIET JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 NORTHWEST BLVD
INDIANAPOLIS IN
46278-1381
US

IV. Provider business mailing address

6445 HARRISON RIDGE BLVD
INDIANAPOLIS IN
46236-7820
US

V. Phone/Fax

Practice location:
  • Phone: 317-802-2000
  • Fax:
Mailing address:
  • Phone: 317-744-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License Number28213834A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: