Provider Demographics
NPI:1144767906
Name:JACKSON, THERESA A (RN BSN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 42ND ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-2113
Mailing Address - Country:US
Mailing Address - Phone:336-587-9076
Mailing Address - Fax:
Practice Address - Street 1:3112 33RD ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-3869
Practice Address - Country:US
Practice Address - Phone:330-454-6430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant