Provider Demographics
NPI:1447808936
Name:PIERSON, JACKIE (CNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:PIERSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 27TH ST STE B06
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-2681
Mailing Address - Country:US
Mailing Address - Phone:740-356-8034
Mailing Address - Fax:740-353-7900
Practice Address - Street 1:7959 STATE ROUTE 124
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:OH
Practice Address - Zip Code:45646-9701
Practice Address - Country:US
Practice Address - Phone:740-493-1800
Practice Address - Fax:740-493-1500
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025524363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0368049Medicaid