Provider Demographics
NPI:1093305054
Name:JACKSON, JAIMI GRANT
Entity Type:Individual
Prefix:
First Name:JAIMI
Middle Name:GRANT
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 1:5000 PENNSYLVANIA AVE STE J
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-1060
Mailing Address - Country:US
Mailing Address - Phone:301-455-9125
Mailing Address - Fax:
Practice Address - Street 1:5000 PENNSYLVANIA AVE STE J
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746-1060
Practice Address - Country:US
Practice Address - Phone:301-455-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4450471744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty