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General NPI Number Information
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NPI Number | 1043173958
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Entity Type | Individual
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Provider Name | ANDREA JACKSON FNP-BC
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Gender | Female
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Dates
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Enumeration Date | 12/08/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 4990 E MEDITERRANEAN DR STE A
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City | SIERRA VISTA
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State | AZ
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Zip | 85635-2495
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Country | US
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Telephone | 520-439-5186
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Fax |
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Provider Business Mailing Address
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Address Line | 3494 HERBA DE MARIA
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City | SIERRA VISTA
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State | AZ
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Zip | 85650-9588
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Country | US
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Telephone | 417-389-9987
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Fax | 417-389-9987
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 309107
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License Number State | AZ
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