Provider Demographics
NPI:1407469679
Name:JACKSON, JONI MAE
Entity Type:Individual
Prefix:
First Name:JONI
Middle Name:MAE
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 1:5168 STATE ROUTE 3&12
Mailing Address - Street 2:
Mailing Address - City:TALCOTT
Mailing Address - State:WV
Mailing Address - Zip Code:24981
Mailing Address - Country:US
Mailing Address - Phone:304-250-5360
Mailing Address - Fax:
Practice Address - Street 1:5168 STATE ROUTE 3&12
Practice Address - Street 2:
Practice Address - City:TALCOTT
Practice Address - State:WV
Practice Address - Zip Code:24981
Practice Address - Country:US
Practice Address - Phone:304-250-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant