Basic Information
| Provider Information | |||||||||
| NPI: | 1508942954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 158 N MAIN ST | ||||||||
| Address2: | PO BOX 299 | ||||||||
| City: | FLORIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109211133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511510 | ||||||||
| Practice Location | |||||||||
| Address1: | 261 N ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852262616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803052888 | ||||||||
| FaxNumber: | 4803052889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2006 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F332937 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 510793 | 01 | RN | OTHER | MJ0564117 | 01 | DEA | OTHER |