Provider Demographics
NPI:1407618192
Name:JACKSON, KAREN A
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:A
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 1:1638 CLUB TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4626
Mailing Address - Country:US
Mailing Address - Phone:161-455-6258
Mailing Address - Fax:
Practice Address - Street 1:1638 CLUB TRAIL DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-4626
Practice Address - Country:US
Practice Address - Phone:614-556-2589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant