Healthcare Provider Details

I. General information

NPI: 1265366579
Provider Name (Legal Business Name): ALEXIS NICOLE JACKSON DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 AIRWAYS BLVD BLDG C4
SOUTHAVEN MS
38671-4114
US

IV. Provider business mailing address

PO BOX 649113
DALLAS TX
75264-9113
US

V. Phone/Fax

Practice location:
  • Phone: 662-404-8630
  • Fax: 662-404-8631
Mailing address:
  • Phone: 662-404-8630
  • Fax: 662-404-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number908482
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: