| NPI | 1942947866 |
|---|---|
| Former Name | THERESA MARIE JACKSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2022012338) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IL 209025107) |
| Enumeration Date | 2022-05-13 |
| Last Update Date | 2022-05-13 |