Healthcare Provider Details

I. General information

NPI: 1588094304
Provider Name (Legal Business Name): AMELIA JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7310 RITCHIE HWY STE 516
GLEN BURNIE MD
21061-3099
US

IV. Provider business mailing address

7310 RITCHIE HWY STE 516
GLEN BURNIE MD
21061-3099
US

V. Phone/Fax

Practice location:
  • Phone: 443-222-2222
  • Fax:
Mailing address:
  • Phone: 443-222-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR193680
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR193680
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: