Suyapa Mariel Jackson, NP

Primary specialty

Primary Care Nurse PractitionerTaxonomy code 363LP2300X

License

906658 Issued in MS

Practice address

1523 Padova Ave
Tontitown, AR 72762-5386

Phone

(601) 209-9031

NPI assigned

Aug 28, 2024

Sex

Female

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Nurse Practitioner

State licenses

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

{
    "created_epoch": "1724803200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724803200000",
    "number": "1659105195",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1523 PADOVA AVE",
            "city": "TONTITOWN",
            "state": "AR",
            "postal_code": "727625386",
            "telephone_number": "601-209-9031"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1523 PADOVA AVE",
            "city": "TONTITOWN",
            "state": "AR",
            "postal_code": "727625386",
            "telephone_number": "601-209-9031"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "SUYAPA",
        "middle_name": "MARIEL",
        "credential": "NP",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-08-28",
        "last_updated": "2024-08-28",
        "certification_date": "2024-08-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LA2200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Adult Health",
            "state": "MS",
            "license": "906658",
            "primary": false
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Gerontology",
            "state": "MS",
            "license": "906658",
            "primary": false
        },
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "MS",
            "license": "906658",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Primary Care Nurse Practitioner in Tontitown, AR
• Providers in Tontitown, AR by specialty
• Primary Care Nurse Practitioner in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.