Provider Demographics
NPI:1083947592
Name:JACKSON, THERESA MICHELLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MICHELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 E 197TH ST
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1121
Mailing Address - Country:US
Mailing Address - Phone:216-738-1774
Mailing Address - Fax:
Practice Address - Street 1:337 E 197TH ST
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44119-1121
Practice Address - Country:US
Practice Address - Phone:216-738-1774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.310131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse