Provider Demographics
NPI:1194340687
Name:JACKSON, CORY DAVID (FNP-BC)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:DAVID
Last Name:JACKSON
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5507 SHAWNEE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3305
Mailing Address - Country:US
Mailing Address - Phone:304-690-0320
Mailing Address - Fax:
Practice Address - Street 1:1340 HAL GREER BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3804
Practice Address - Country:US
Practice Address - Phone:304-399-6727
Practice Address - Fax:304-399-6726
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV96293363LF0000X, 163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency