Healthcare Provider Details

I. General information

NPI: 1669307930
Provider Name (Legal Business Name): NYASHA MALIKA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 N 29TH ST APT 206
OMAHA NE
68111-3838
US

IV. Provider business mailing address

2120 N 29TH ST APT 206
OMAHA NE
68111-3838
US

V. Phone/Fax

Practice location:
  • Phone: 531-215-5488
  • Fax:
Mailing address:
  • Phone: 531-215-5488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: