Healthcare Provider Details

I. General information

NPI: 1992958128
Provider Name (Legal Business Name): CHRISTINE E JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE E VENCIS FNP

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MERRIMACK ST
LAWRENCE MA
01843-1756
US

IV. Provider business mailing address

477 ANDOVER ST
NORTH ANDOVER MA
01845-5036
US

V. Phone/Fax

Practice location:
  • Phone: 978-557-8900
  • Fax: 978-557-8856
Mailing address:
  • Phone: 978-837-5441
  • Fax: 978-837-5557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number260098
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: