Provider Demographics
NPI:1124499124
Name:NISHA JACKSON INC.
Entity type:Organization
Organization Name:NISHA JACKSON INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NISHA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:541-494-9355
Mailing Address - Street 1:3236 HILLCREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7657
Mailing Address - Country:US
Mailing Address - Phone:541-494-9355
Mailing Address - Fax:541-494-0945
Practice Address - Street 1:3265 HILLCREST PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7657
Practice Address - Country:US
Practice Address - Phone:541-494-9355
Practice Address - Fax:541-210-8724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-15
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086006299N7363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR012158Medicaid
OR012158Medicaid