Healthcare Provider Details

I. General information

NPI: 1144963059
Provider Name (Legal Business Name): KEVA S JACKSON FNP-BC, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W LEXINGTON ST STE 240
BALTIMORE MD
21201-3411
US

IV. Provider business mailing address

5017 OLD COURT RD
RANDALLSTOWN MD
21133-4630
US

V. Phone/Fax

Practice location:
  • Phone: 443-762-4745
  • Fax: 240-924-3412
Mailing address:
  • Phone: 443-392-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP500015383
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR151343
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP500015383
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR151343
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: