{
"Npi": {
"NPI": "1144399270",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "N",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "JACKSON",
"FirstName": "RENITRA",
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": "FNP",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 776084",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CHICAGO",
"MailingAddressStateName": "IL",
"MailingAddressPostalCode": "60677-0019",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "314-831-8600",
"MailingAddressFaxNumber": "314-831-0086",
"FirstLinePracticeLocationAddress": "637 DUNN RD STE 102A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "HAZELWOOD",
"PracticeLocationAddressStateName": "MO",
"PracticeLocationAddressPostalCode": "63042-1755",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "314-831-8600",
"PracticeLocationAddressFaxNumber": "314-839-5596",
"EnumerationDate": "11/06/2006",
"LastUpdateDate": "08/16/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363LF0000X",
"TaxonomyName": "Family Nurse Practitioner",
"LicenseNumber": "2000164715",
"LicenseNumberStateCode": "MO",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}