Provider Demographics
NPI:1861738486
Name:EDWARD, JAKSON NICHOLAS
Entity type:Individual
Prefix:
First Name:JAKSON
Middle Name:NICHOLAS
Last Name:EDWARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1865 RAINBOW RD APT 106
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6583
Mailing Address - Country:US
Mailing Address - Phone:307-275-2640
Mailing Address - Fax:
Practice Address - Street 1:4585 SW 185TH AVE
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97078-1557
Practice Address - Country:US
Practice Address - Phone:503-591-9280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY132080700251B00000X
OR202106698RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No251B00000XAgenciesCase Management