Healthcare Provider Details

I. General information

NPI: 1154747103
Provider Name (Legal Business Name): REBECCA L JACKSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 KILVERT ST STE 300
WARWICK RI
02886-1360
US

IV. Provider business mailing address

863 RIVER AVE
PROVIDENCE RI
02908-1424
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-6900
  • Fax:
Mailing address:
  • Phone: 857-939-9274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCAPRN01179
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: