| NPI | 1427018704 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER L JACKSON Sr. Director Provider Enrollment 877-892-9815 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 207R00000X Internal Medicine |
| 363L00000X Nurse Practitioner | |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2022-03-05 |