Provider Demographics
NPI:1083192660
Name:JACKSON, DEVONA
Entity Type:Individual
Prefix:
First Name:DEVONA
Middle Name:
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 1:1117 MCCOLLOUGH CT NW APT 103
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-3695
Mailing Address - Country:US
Mailing Address - Phone:202-300-5356
Mailing Address - Fax:
Practice Address - Street 1:612 EMMANUEL CT NW APT 104
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3413
Practice Address - Country:US
Practice Address - Phone:202-300-5356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant