Provider Demographics
NPI:1154671816
Name:JACKSON, JAMIE KAY
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:KAY
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 1:7409 PATRICK HENRY CT
Mailing Address - Street 2:APT. 8
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-5239
Mailing Address - Country:US
Mailing Address - Phone:502-876-4548
Mailing Address - Fax:
Practice Address - Street 1:7409 PATRICK HENRY CT
Practice Address - Street 2:APT. 8
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-5239
Practice Address - Country:US
Practice Address - Phone:502-876-4548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50178368374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50178368OtherKENTUCKY NURSE AIDE REGISTRY