Healthcare Provider Details

I. General information

NPI: 1477076404
Provider Name (Legal Business Name): NATALIE R JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W UNIVERSITY AVE FL 3
MUNCIE IN
47303-3428
US

IV. Provider business mailing address

240 N TILLOTSON AVE
MUNCIE IN
47304-3988
US

V. Phone/Fax

Practice location:
  • Phone: 765-747-4409
  • Fax:
Mailing address:
  • Phone: 765-288-1928
  • Fax: 765-741-0335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512855
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: