Healthcare Provider Details

I. General information

NPI: 1568961837
Provider Name (Legal Business Name): EVELYN NICOLE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 PARR AVE
DYERSBURG TN
38024-2004
US

IV. Provider business mailing address

497 LITTLE RD
MARTIN TN
38237-5440
US

V. Phone/Fax

Practice location:
  • Phone: 731-285-7311
  • Fax:
Mailing address:
  • Phone: 731-514-1707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23714
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: