Healthcare Provider Details

I. General information

NPI: 1336411172
Provider Name (Legal Business Name): CHERI LYNN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 LAUREL OAK RD
VOORHEES NJ
08043-4419
US

IV. Provider business mailing address

132 SOUTH 10 TH STREET SUITE 480
PHILADELPHIA PA
19107
US

V. Phone/Fax

Practice location:
  • Phone: 856-741-0122
  • Fax:
Mailing address:
  • Phone: 215-955-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00364800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: