Provider Demographics
NPI:1144399270
Name:JACKSON, RENITRA (FNP)
Entity type:Individual
Prefix:
First Name:RENITRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0019
Mailing Address - Country:US
Mailing Address - Phone:314-831-8600
Mailing Address - Fax:314-831-0086
Practice Address - Street 1:637 DUNN RD STE 102A
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1755
Practice Address - Country:US
Practice Address - Phone:314-831-8600
Practice Address - Fax:314-839-5596
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000164715363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000164715Medicaid
MO1144399270Medicaid
MO991390041Medicare PIN