MEDICARE: NICHOLE ROSE JACKSON NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R31008	ND

General Provider Information

NPI Number	:	1184988438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE ROSE JACKSON NP-C

Provider Business Mailing Address
First Line	:	530 3RD ST E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-2711
Country	:	US
Telephone Number	:	701-205-3088
Fax Number	:	701-335-7808

Provider Business Practice Location Address
First Line	:	3175 SIENNA DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-8910
Country	:	US
Telephone Number	:	701-205-3088
Fax Number	:	701-335-7808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2012
Last Update Date	:	09/23/2016

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