Healthcare Provider Details

I. General information

NPI: 1437080124
Provider Name (Legal Business Name): ANDREA MARIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E FRONT AVE STE 102
BISMARCK ND
58504-5689
US

IV. Provider business mailing address

830 STAGECOACH CIR
BISMARCK ND
58503-8832
US

V. Phone/Fax

Practice location:
  • Phone: 701-975-6400
  • Fax: 844-670-8600
Mailing address:
  • Phone: 406-672-9856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number204935
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: