Provider Demographics
NPI:1467721829
Name:JACKSON, CLISSIE TERERSA (HOME CARE)
Entity Type:Individual
Prefix:
First Name:CLISSIE
Middle Name:TERERSA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HOME CARE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 74TH ST N
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35206-4261
Mailing Address - Country:US
Mailing Address - Phone:313-358-0035
Mailing Address - Fax:186-665-9907
Practice Address - Street 1:208 74TH ST N
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35206-4261
Practice Address - Country:US
Practice Address - Phone:313-358-0035
Practice Address - Fax:186-665-9907
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119405B376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide