Provider Demographics
NPI:1336703974
Name:JACKSON, MEGHAN NICOLE (NP)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:NICOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:616-840-9642
Practice Address - Street 1:235 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5247
Practice Address - Country:US
Practice Address - Phone:616-840-8000
Practice Address - Fax:616-840-9642
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001617363L00000X
MI4704420354363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner