Provider Demographics
NPI:1033713458
Name:JACKSON, KAITLIN MICHELL
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FOURTH ROAD
Mailing Address - Street 2:
Mailing Address - City:CRAIGSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26205
Mailing Address - Country:US
Mailing Address - Phone:681-208-4457
Mailing Address - Fax:304-471-2488
Practice Address - Street 1:8 N SPRING ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2720
Practice Address - Country:US
Practice Address - Phone:304-472-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker