Provider Demographics
NPI:1972336923
Name:JACKSON, KEISHA PERRY (PMHNP)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:PERRY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 EAGLE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-1206
Mailing Address - Country:US
Mailing Address - Phone:662-629-2209
Mailing Address - Fax:
Practice Address - Street 1:302 EAGLE VIEW DR
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-1206
Practice Address - Country:US
Practice Address - Phone:662-629-2209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health