1558956235 NPI number — MRS. TRICIA MARIE JACKSON CRNP

Table of content: DR. JUSTON FAN DO (NPI 1326537044)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558956235 NPI number — MRS. TRICIA MARIE JACKSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
JACKSON

Provider First Name:
TRICIA

Provider Middle Name:
MARIE

Provider Name Prefix Text:
MRS.

Provider Name Suffix Text:

Provider Credential Text:
CRNP

Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558956235

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/06/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8124 VETERANS HWY

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MILLERSVILLE

Provider Business Mailing Address State Name:
MD

Provider Business Mailing Address Postal Code:
21108-1412

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
410-987-5244

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8124 VETERANS HWY

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
MILLERSVILLE

Provider Business Practice Location Address State Name:
MD

Provider Business Practice Location Address Postal Code:
21108-1412

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
410-987-5244

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
03/04/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 363LF0000X , with the licence number: R214869 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .