Healthcare Provider Details

I. General information

NPI: 1376116095
Provider Name (Legal Business Name): ERICA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 E LOCKWOOD AVE
SAINT LOUIS MO
63119-3194
US

IV. Provider business mailing address

1270 N WICKHAM RD STE 16-705
MELBOURNE FL
32935-8923
US

V. Phone/Fax

Practice location:
  • Phone: 800-981-9801
  • Fax:
Mailing address:
  • Phone: 321-216-7875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: