Healthcare Provider Details

I. General information

NPI: 1972333870
Provider Name (Legal Business Name): JILL MARIE JACKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 BLUEGRASS AVE
LOUISVILLE KY
40215-1161
US

IV. Provider business mailing address

1958 DEER PARK AVE APT 1
LOUISVILLE KY
40205-2265
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-6391
  • Fax:
Mailing address:
  • Phone: 502-345-8128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number1152343
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: