Provider Demographics
NPI:1134518392
Name:JACKSON, KAYLA LYNN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:LYNN
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:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-0045
Mailing Address - Country:US
Mailing Address - Phone:937-926-6420
Mailing Address - Fax:
Practice Address - Street 1:10965 WEST STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:ROSEWOOD
Practice Address - State:OH
Practice Address - Zip Code:43070
Practice Address - Country:US
Practice Address - Phone:937-926-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0112400347C00000X, 376J00000X, 385H00000X
OH401084350510376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No347C00000XTransportation ServicesPrivate Vehicle
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401084350510OtherSTATE TESTED NURSE AIDE
OH0112400Medicaid