Healthcare Provider Details

I. General information

NPI: 1295484566
Provider Name (Legal Business Name): NISHA JACKSON COMPANIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3265 HILLCREST PARK DR
MEDFORD OR
97504-7657
US

IV. Provider business mailing address

3265 HILLCREST PARK DR
MEDFORD OR
97504-7657
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NISHA JACKSON
Title or Position: OWNER
Credential:
Phone: 541-494-9355