Healthcare Provider Details

I. General information

NPI: 1932676194
Provider Name (Legal Business Name): ELLANIKOLE JACKSON DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11268 HIGHWAY 57
COUNCE TN
38326-3802
US

IV. Provider business mailing address

PO BOX 140
PICKWICK DAM TN
38365-0140
US

V. Phone/Fax

Practice location:
  • Phone: 731-438-3456
  • Fax:
Mailing address:
  • Phone: 731-689-4357
  • Fax: 731-689-1050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24869
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: