Provider Demographics
NPI:1346705720
Name:JACKSON, CANDICE LATRICE (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:LATRICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:LATRICE
Other - Last Name:PARRISH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP, PMHNP
Mailing Address - Street 1:5140 E SOUTHPORT RD # 1030
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9601
Mailing Address - Country:US
Mailing Address - Phone:317-493-6456
Mailing Address - Fax:463-388-2323
Practice Address - Street 1:600 E CARMEL DR STE 117
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3049
Practice Address - Country:US
Practice Address - Phone:463-999-9203
Practice Address - Fax:463-388-2323
Is Sole Proprietor?:No
Enumeration Date:2019-02-10
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009203A363LF0000X
IN71009203B363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily