Provider Demographics
NPI:1164208559
Name:JACKSON, SOPHIA LOREN
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:LOREN
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 1:6863 KINSTON DR
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-9325
Mailing Address - Country:US
Mailing Address - Phone:614-209-4699
Mailing Address - Fax:
Practice Address - Street 1:6863 KINSTON DR
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-9325
Practice Address - Country:US
Practice Address - Phone:614-209-4699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide