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General NPI Number Information
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NPI Number | 1184988438
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Entity Type | Individual
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Provider Name | NICHOLE ROSE JACKSON NP-C
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Gender | Female
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Dates
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Enumeration Date | 07/02/2012
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Last Update Date | 09/23/2016
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Provider Practice Location Address
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Address Line | 3175 SIENNA DR S
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City | FARGO
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State | ND
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Zip | 58104-8910
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Country | US
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Telephone | 701-205-3088
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Fax | 701-335-7808
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Provider Business Mailing Address
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Address Line | 530 3RD ST E
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City | WEST FARGO
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State | ND
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Zip | 58078-2711
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Country | US
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Telephone | 701-205-3088
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Fax | 701-335-7808
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | R31008
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License Number State | ND
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