Provider Demographics
NPI:1043753403
Name:JACKSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8483 TORWOODLEE CT # 8483
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-9739
Mailing Address - Country:US
Mailing Address - Phone:614-203-8546
Mailing Address - Fax:
Practice Address - Street 1:4646 HILTON CORPORATE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4147
Practice Address - Country:US
Practice Address - Phone:614-914-4541
Practice Address - Fax:614-866-8580
Is Sole Proprietor?:No
Enumeration Date:2016-12-02
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020277363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily