Healthcare Provider Details

I. General information

NPI: 1730801531
Provider Name (Legal Business Name): SOPHIE JACKSON RN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST STE 150
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

123 SUMMER ST STE 150
WORCESTER MA
01608-1216
US

V. Phone/Fax

Practice location:
  • Phone: 508-368-3110
  • Fax:
Mailing address:
  • Phone: 508-368-3110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN10000713
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN315147
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN10000713
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: