Healthcare Provider Details

I. General information

NPI: 1356861751
Provider Name (Legal Business Name): NELLA JACKSON PERRELLA MSN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NELLA JEANNINE JACKSON MSN, FNP

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 BUTTERMILK PIKE
CRESCENT SPRINGS KY
41017
US

IV. Provider business mailing address

2883 MARKBREIT AVE
CINCINNATI OH
45209-2019
US

V. Phone/Fax

Practice location:
  • Phone: 859-344-1824
  • Fax:
Mailing address:
  • Phone: 770-301-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN223408
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.022420
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012187
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: