Healthcare Provider Details

I. General information

NPI: 1386005460
Provider Name (Legal Business Name): INAISHA MARIE JACKSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: INAISHA M JACKSON APN

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RUTGERS, UNIVERSITY BEHAVIORAL HEALTH CARE BATES BUILDING, 2ND FLOOR
TRENTON NJ
08625863
US

IV. Provider business mailing address

5450 WISSAHICKON AVE APT A1103
PHILADELPHIA PA
19144-5261
US

V. Phone/Fax

Practice location:
  • Phone: 609-292-9700
  • Fax:
Mailing address:
  • Phone: 862-520-9487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ00625000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: