Healthcare Provider Details

I. General information

NPI: 1861302895
Provider Name (Legal Business Name): PETRA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 HUNTINGTON AVE
BOSTON MA
02115-5005
US

IV. Provider business mailing address

360 HUNTINGTON AVE 202 ROBINSON HALL
BOSTON MA
02115-5005
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-3195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: