Provider Demographics
NPI:1154970846
Name:JACKSON, ANDREA DELOIS (FNP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:DELOIS
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-4901
Mailing Address - Country:US
Mailing Address - Phone:559-582-0397
Mailing Address - Fax:
Practice Address - Street 1:1114 W 6TH ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4901
Practice Address - Country:US
Practice Address - Phone:559-582-0397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95012994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily