Provider Demographics
NPI:1447060702
Name:JACKSON, CLANTRELLE
Entity type:Individual
Prefix:
First Name:CLANTRELLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 S BLACKHAWK ST STE 240
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1475
Mailing Address - Country:US
Mailing Address - Phone:501-613-7863
Mailing Address - Fax:580-297-9105
Practice Address - Street 1:2101 S BLACKHAWK ST STE 240
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1475
Practice Address - Country:US
Practice Address - Phone:501-613-7863
Practice Address - Fax:580-297-9105
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11035553363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health