Provider Demographics
NPI:1104436146
Name:JACKSON, ALISIA (APRN)
Entity type:Individual
Prefix:
First Name:ALISIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16605 CHESTNUT GLEN PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-6121
Mailing Address - Country:US
Mailing Address - Phone:502-709-0430
Mailing Address - Fax:
Practice Address - Street 1:9204 TAYLORSVILLE RD STE 217
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1789
Practice Address - Country:US
Practice Address - Phone:502-709-0430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011085A363LF0000X
KY3013490363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100720690Medicaid