1396717286 NPI number — MS. SANDRA F JACKSON CRNP

Table of content: MS. SANDRA F JACKSON CRNP (NPI 1396717286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396717286 NPI number — MS. SANDRA F JACKSON CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
SANDRA
Provider Middle Name:
F
Provider Name Prefix Text:
MS.
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:
1396717286
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 W 37TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19802-2225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-450-4551
Provider Business Mailing Address Fax Number:
302-355-2550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 W 37TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19802-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-450-4551
Provider Business Practice Location Address Fax Number:
302-355-2550
Provider Enumeration Date:
02/03/2006

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:  LG-0000519 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: SP008227 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1396717286 363L00000 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107786800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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