Provider Demographics
NPI:1407204274
Name:JACKSON, NONI TENE I
Entity Type:Individual
Prefix:
First Name:NONI
Middle Name:TENE
Last Name:JACKSON
Suffix:I
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 1:14505 OAKMERE DR
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1390
Mailing Address - Country:US
Mailing Address - Phone:651-492-9511
Mailing Address - Fax:708-778-2332
Practice Address - Street 1:14505 OAKMERE DR
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-1390
Practice Address - Country:US
Practice Address - Phone:651-492-9511
Practice Address - Fax:708-778-2332
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator