Provider Demographics
NPI:1336510692
Name:JACKSON, KAMILAH
Entity Type:Individual
Prefix:
First Name:KAMILAH
Middle Name:
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 1:16 GOLF RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-1607
Mailing Address - Country:US
Mailing Address - Phone:610-924-5217
Mailing Address - Fax:
Practice Address - Street 1:16 GOLF RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-1607
Practice Address - Country:US
Practice Address - Phone:610-924-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion