Provider Demographics
NPI:1326551607
Name:JACKSON, RACHEL NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:NICOLE
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:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-0108
Mailing Address - Country:US
Mailing Address - Phone:740-532-1613
Mailing Address - Fax:740-532-1715
Practice Address - Street 1:418 CENTER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1712
Practice Address - Country:US
Practice Address - Phone:740-776-2785
Practice Address - Fax:740-776-2793
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.175596.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273628Medicaid