Provider Demographics
NPI:1487266078
Name:JACKSON, ALYSSA JANE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 MN AVE
Mailing Address - Street 2:
Mailing Address - City:SEBEKA
Mailing Address - State:MN
Mailing Address - Zip Code:56477
Mailing Address - Country:US
Mailing Address - Phone:218-837-5333
Mailing Address - Fax:
Practice Address - Street 1:106 MN AVE
Practice Address - Street 2:
Practice Address - City:SEBEKA
Practice Address - State:MN
Practice Address - Zip Code:56477
Practice Address - Country:US
Practice Address - Phone:218-837-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR49629363LF0000X
MN7592363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily