Provider Demographics
NPI:1962583971
Name:JACKSON, PRISCILLA (CFNP)
Entity type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 N PALESTINE RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-9007
Mailing Address - Country:US
Mailing Address - Phone:601-597-0229
Mailing Address - Fax:
Practice Address - Street 1:225 COMMUNITY DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MS
Practice Address - Zip Code:39069
Practice Address - Country:US
Practice Address - Phone:601-786-8206
Practice Address - Fax:601-786-6320
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852296363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0121708Medicaid
LA1783048Medicaid