Healthcare Provider Details

I. General information

NPI: 1740197227
Provider Name (Legal Business Name): NICOLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MALL RD
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

31 MALL RD
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-2679
  • Fax:
Mailing address:
  • Phone: 781-744-2679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number2269008
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: