Provider Demographics
NPI:1730079310
Name:JACKSON, MARLEY (NP)
Entity type:Individual
Prefix:
First Name:MARLEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 959354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-9354
Mailing Address - Country:US
Mailing Address - Phone:636-916-7060
Mailing Address - Fax:636-916-9421
Practice Address - Street 1:70 JUNGERMANN CIR STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1637
Practice Address - Country:US
Practice Address - Phone:636-916-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2025018317363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner