Nichole Rose Jackson, NP-C

Primary specialty

Nurse PractitionerTaxonomy code 363L00000X

License

R31008 Issued in ND

Practice address

3175 Sienna Dr S
Fargo, ND 58104-8910

Phone

(701) 205-3088

Fax

(701) 335-7808

NPI assigned

Jul 2, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Nichole Jackson Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Oct 1, 2016 through Oct 1, 2026

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1341187200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1474588800000",
    "number": "1184988438",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "530 3RD ST E",
            "city": "WEST FARGO",
            "state": "ND",
            "postal_code": "580782711",
            "telephone_number": "701-205-3088",
            "fax_number": "701-335-7808"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3175 SIENNA DR S",
            "city": "FARGO",
            "state": "ND",
            "postal_code": "581048910",
            "telephone_number": "701-205-3088",
            "fax_number": "701-335-7808"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "NICHOLE",
        "middle_name": "ROSE",
        "credential": "NP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-07-02",
        "last_updated": "2016-09-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "ND",
            "license": "R31008",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICHOLE",
            "last_name": "JACKSON",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Adam W Jackson, M.D.
• Kenita Jackson
• Mackenzie Cory-Rae Jackson
• Madeline Ruth Jackson, SLP
• Melissa Jackson, MSW, LMSW
• Anna Jacobawi
• Alphonso S Jacobs
• Erica Jacobs
• Johannes Jacobus Jacobs, MD
• Katie Jo Jacobs, PA

• Nurse Practitioner in Fargo, ND
• Providers in Fargo, ND by specialty
• Nurse Practitioner in North Dakota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.