Healthcare Provider Details

I. General information

NPI: 1184277857
Provider Name (Legal Business Name): DOUGLAS JACKSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICE
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3000
  • Fax: 765-935-8944
Mailing address:
  • Phone: 765-935-5331
  • Fax: 765-983-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71009145A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0027550
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: