Provider Demographics
NPI:1104354901
Name:JACKSON, JANICE SUE (ND)
Entity type:Individual
Prefix:DR
First Name:JANICE
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17844
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85269-7844
Mailing Address - Country:US
Mailing Address - Phone:480-886-3059
Mailing Address - Fax:480-900-7150
Practice Address - Street 1:12052 N SAGUARO BLVD UNIT 201
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-4673
Practice Address - Country:US
Practice Address - Phone:480-886-3059
Practice Address - Fax:480-900-7150
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16-1551175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath