Provider Demographics
NPI:1225770886
Name:JACKSON, NAKEISHA L (LPN)
Entity Type:Individual
Prefix:MRS
First Name:NAKEISHA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1131
Mailing Address - Country:US
Mailing Address - Phone:917-645-3217
Mailing Address - Fax:585-730-4875
Practice Address - Street 1:131 NORMANDY AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-1131
Practice Address - Country:US
Practice Address - Phone:917-645-3217
Practice Address - Fax:585-730-4875
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33873801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse