Healthcare Provider Details

I. General information

NPI: 1699308569
Provider Name (Legal Business Name): HEATHER E JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PLAZA DR STE C
SIKESTON MO
63801-5105
US

IV. Provider business mailing address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-481-2210
  • Fax: 573-481-2220
Mailing address:
  • Phone: 573-471-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020003588
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: