Provider Demographics
NPI:1235809237
Name:KMJACKSON
Entity Type:Organization
Organization Name:KMJACKSON
Other - Org Name:KMJACKSON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-402-9641
Mailing Address - Street 1:2020 BROWNLEE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1016
Mailing Address - Country:US
Mailing Address - Phone:330-402-9641
Mailing Address - Fax:
Practice Address - Street 1:2020 BROWNLEE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-1016
Practice Address - Country:US
Practice Address - Phone:330-402-9641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1235809237Medicaid
OH1073119525OtherNPI