Healthcare Provider Details

I. General information

NPI: 1235458100
Provider Name (Legal Business Name): LINDA ANN JACKSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

IV. Provider business mailing address

60 LINDEN AVE
FAIRHAVEN MA
02719-3257
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-7100
  • Fax:
Mailing address:
  • Phone: 508-997-8431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN34586
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN214244
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: