Provider Demographics
NPI:1932377702
Name:JACKSON, JOYCE JACQUETTA (NP)
Entity type:Individual
Prefix:MS
First Name:JOYCE
Middle Name:JACQUETTA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:3450 OLD WASHINGTON ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3248
Mailing Address - Country:US
Mailing Address - Phone:301-645-3590
Mailing Address - Fax:301-705-1941
Practice Address - Street 1:3450 OLD WASHINGTON ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3248
Practice Address - Country:US
Practice Address - Phone:301-645-3590
Practice Address - Fax:301-705-1941
Is Sole Proprietor?:No
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR109047363L00000X
VA0024167148363L00000X
CA622905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner