Provider Demographics
NPI:1083214464
Name:JACKSON, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
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 1:148 LITTLE SHADY LN
Mailing Address - Street 2:
Mailing Address - City:HARPERS FERRY
Mailing Address - State:WV
Mailing Address - Zip Code:25425-6644
Mailing Address - Country:US
Mailing Address - Phone:240-529-4027
Mailing Address - Fax:
Practice Address - Street 1:148 LITTLE SHADY LN
Practice Address - Street 2:
Practice Address - City:HARPERS FERRY
Practice Address - State:WV
Practice Address - Zip Code:25425-6644
Practice Address - Country:US
Practice Address - Phone:240-529-4027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant