Basic Information
| Provider Information | |||||||||
| NPI: | 1447808936 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIERSON | ||||||||
| FirstName: | JACKIE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 27TH ST STE B06 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456622681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403568034 | ||||||||
| FaxNumber: | 7403537900 | ||||||||
| Practice Location | |||||||||
| Address1: | 7959 STATE ROUTE 124 | ||||||||
| Address2: | |||||||||
| City: | LATHAM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456469701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404931800 | ||||||||
| FaxNumber: | 7404931500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 12/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN.CNP.025524 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0368049 | 05 | OH | MEDICAID |