Provider Demographics
NPI:1265037097
Name:JACKSON, BIANCA A
Entity Type:Individual
Prefix:
First Name:BIANCA
Middle Name:A
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 1:73 COLONIAL HILLS DR
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44310-2359
Mailing Address - Country:US
Mailing Address - Phone:330-926-8680
Mailing Address - Fax:
Practice Address - Street 1:73 COLONIAL HILLS DR
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44310-2359
Practice Address - Country:US
Practice Address - Phone:330-926-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker