Provider Demographics
NPI:1396392684
Name:JACKSON, CHRISTIANA MARIE (AT)
Entity Type:Individual
Prefix:
First Name:CHRISTIANA
Middle Name:MARIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 RICHLAND AVE APT 5119
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-3262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10397 STATE ROUTE 155 SE
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:OH
Practice Address - Zip Code:43730-9710
Practice Address - Country:US
Practice Address - Phone:740-394-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH27829682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2782968OtherALLIED HEALTH PROFESSIONAL LIABILITY