Basic Information
| Provider Information | |||||||||
| NPI: | 1003250143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKENS | ||||||||
| FirstName: | JANN | ||||||||
| MiddleName: | STACEY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13917 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191013917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SHADOW LN | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023884506 | ||||||||
| FaxNumber: | 7023884810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APN001525 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | APRN001525 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.