Healthcare Provider Details

I. General information

NPI: 1093285496
Provider Name (Legal Business Name): CHRISTOPHER M JACKSON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2018
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 KENSINGTON AVE
FLINT MI
48503-2044
US

IV. Provider business mailing address

204 PINE ST
CORUNNA MI
48817-1031
US

V. Phone/Fax

Practice location:
  • Phone: 810-762-8400
  • Fax:
Mailing address:
  • Phone: 810-449-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704247130
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: