Provider Demographics
NPI:1447911847
Name:JACKSON, NATASHA (RN)
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7360 CRYSTAL LAKE DR APT 6
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8942
Mailing Address - Country:US
Mailing Address - Phone:810-597-1514
Mailing Address - Fax:
Practice Address - Street 1:7360 CRYSTAL LAKE DR APT 6
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-8942
Practice Address - Country:US
Practice Address - Phone:810-597-1514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704344257163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse