Provider Demographics
NPI:1952293573
Name:JACKSON, ARCHIA DENISE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:ARCHIA
Middle Name:DENISE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5593 CORYDALIS DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1685
Mailing Address - Country:US
Mailing Address - Phone:989-493-1964
Mailing Address - Fax:989-493-1964
Practice Address - Street 1:3075 ORCHARD VISTA DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7069
Practice Address - Country:US
Practice Address - Phone:989-493-1964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704235782163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health