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General NPI Number Information
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NPI Number | 1346705720
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Entity Type | Individual
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Provider Name | CANDICE LATRICE JACKSON FNP, PMHNP
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Gender | Female
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Dates
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Enumeration Date | 02/10/2019
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Last Update Date | 01/25/2025
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Provider Practice Location Address
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Address Line | 600 E CARMEL DR STE 117
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City | CARMEL
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State | IN
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Zip | 46032-3049
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Country | US
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Telephone | 463-999-9203
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Fax | 463-388-2323
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Provider Business Mailing Address
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Address Line | 5140 E SOUTHPORT RD # 1030
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City | SOUTHPORT
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State | IN
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Zip | 46237-9601
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Country | US
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Telephone | 317-493-6456
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Fax | 463-388-2323
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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 | 71009203A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 71009203B
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License Number State | IN
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