Provider Demographics
NPI:1215561865
Name:JACKSON, JANELLA (RN)
Entity Type:Individual
Prefix:
First Name:JANELLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NMB BUSINESS CENTER 1019 HWY 17S SUITE 115
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582
Mailing Address - Country:US
Mailing Address - Phone:843-273-5022
Mailing Address - Fax:843-273-5022
Practice Address - Street 1:NORTH MYRTLE BEACH BUSINESS CENTER SUITE 115
Practice Address - Street 2:1019 HWY 17S
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582
Practice Address - Country:US
Practice Address - Phone:843-273-5022
Practice Address - Fax:843-273-5022
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-22
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCICPH-1221253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care