Provider Demographics
NPI:1174863922
Name:JACKSON, LUEWANA KIM
Entity Type:Individual
Prefix:MRS
First Name:LUEWANA
Middle Name:KIM
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 1:4466 KIMMEL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43224-1131
Mailing Address - Country:US
Mailing Address - Phone:614-262-3559
Mailing Address - Fax:
Practice Address - Street 1:4466 KIMMEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-1131
Practice Address - Country:US
Practice Address - Phone:614-262-3559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-14
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor