Healthcare Provider Details

I. General information

NPI: 1124499124
Provider Name (Legal Business Name): NISHA JACKSON INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2015
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 HILLCREST PARK DR
MEDFORD OR
97504-7657
US

IV. Provider business mailing address

3236 HILLCREST PARK DR
MEDFORD OR
97504-7657
US

V. Phone/Fax

Practice location:
  • Phone: 541-494-9355
  • Fax: 541-210-8724
Mailing address:
  • Phone: 541-494-9355
  • Fax: 541-494-0945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number086006299N7
License Number StateOR

VIII. Authorized Official

Name: MS. NISHA MARIE JACKSON
Title or Position: OWNER/PRESIDENT
Credential: NP
Phone: 541-494-9355