38D2114957 CLIA NUMBER - NISHA JACKSON INC DBA PEAK MEDICAL PRACTICE

Laboratory Demographics

CLIA Number: 38D2114957

Facility Name: NISHA JACKSON INC DBA PEAK MEDICAL PRACTICE

Facility Address:
1700 NW GARDEN VALLEY BLVD SUITE 201
ROSEBURG, OR
ZIP 97471
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Facility Phone Number: 541 464-0788

Facility Type: Practitioner Other

Certificate Type: Microscopy

NPI Number: 1932656931

Taxonomy: 363LF0000X - Nurse Practitioner

CLIA Record

Field Name	Field Value
CLIA Number	38D2114957
LAB Type	Practitioner Other
Facility Name	NISHA JACKSON INC DBA PEAK MEDICAL PRACTICE
Street	1700 NW GARDEN VALLEY BLVD SUITE 201
City	ROSEBURG
State	OR
ZIP	97471
Phone	541 464-0788
CertificateType	3
CertificateEffectiveDate	6/24/2022
CertificateExpirationDate	6/23/2024
FacilityType	PPMP

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This page was last updated on: 4/23/2024