Provider Demographics
NPI:1306536545
Name:JACKSON, MARIALIZA GODOY PADILLA (APRN, MSN,PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MARIALIZA GODOY
Middle Name:PADILLA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:APRN, MSN,PMHNP-BC
Other - Prefix:
Other - First Name:MARIA LIZA
Other - Middle Name:GODOY
Other - Last Name:LAURETA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:51999 COPPER CREEK CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-5968
Mailing Address - Country:US
Mailing Address - Phone:586-275-9658
Mailing Address - Fax:
Practice Address - Street 1:51999 COPPER CREEK CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-5968
Practice Address - Country:US
Practice Address - Phone:586-275-9658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704188063363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health