Provider Demographics
NPI:1386415578
Name:JACKSON, JACQUELYNNE (RN, BSN)
Entity type:Individual
Prefix:
First Name:JACQUELYNNE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:119 RED FOX RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2242
Mailing Address - Country:US
Mailing Address - Phone:618-444-5071
Mailing Address - Fax:
Practice Address - Street 1:1 JEFFERSON BARRACKS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-4181
Practice Address - Country:US
Practice Address - Phone:314-894-6654
Practice Address - Fax:314-894-5775
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse