Provider Demographics
NPI:1033627617
Name:JACKSON, LANESHA LARAY (STNA)
Entity Type:Individual
Prefix:
First Name:LANESHA
Middle Name:LARAY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 ZAHN DR APT D
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-5513
Mailing Address - Country:US
Mailing Address - Phone:330-990-5122
Mailing Address - Fax:
Practice Address - Street 1:506 ZAHN DR APT D
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5513
Practice Address - Country:US
Practice Address - Phone:330-990-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4009515907093747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0238874Medicaid