Basic Information
| Provider Information | |||||||||
| NPI: | 1871041657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | SIMONE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 BLAIR MILL RD | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2679082465 | ||||||||
| FaxNumber: | 8773838544 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 BLAIR MILL RD | ||||||||
| Address2: | |||||||||
| City: | HORSHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190442223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159029014 | ||||||||
| FaxNumber: | 8773838544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN162091 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | SP019087 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.