Basic Information
Provider Information | |||||||||
NPI: | 1598903270 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON-PARKIN | ||||||||
FirstName: | MARANDA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACKSON | ||||||||
OtherFirstName: | MARANDA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 100 IRVING STREET | ||||||||
Address2: | MEDSTAR DIABETES INSTITUTE, ROOM 4131 | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 20010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4807030248 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 901 HARRY S TRUMAN DR N | ||||||||
Address2: |   | ||||||||
City: | UPPER MARLBORO | ||||||||
State: | MD | ||||||||
PostalCode: | 207745477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2406773000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/03/2009 | ||||||||
LastUpdateDate: | 07/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | R168458 | MD | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   | 363LA2100X | R168458 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.