1144399270 NPI number — RENITRA JACKSON FNP

Table of content: RENITRA JACKSON FNP (NPI 1144399270)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144399270 NPI number — RENITRA JACKSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
RENITRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1144399270
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776084
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-0019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-831-8600
Provider Business Mailing Address Fax Number:
314-831-0086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
637 DUNN RD STE 102A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZELWOOD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63042-1755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-831-8600
Provider Business Practice Location Address Fax Number:
314-839-5596
Provider Enumeration Date:
11/06/2006

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:  2000164715 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2000164715 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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