Provider Demographics
NPI:1477051845
Name:JACKSON, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
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:PO BOX 482
Mailing Address - Street 2:
Mailing Address - City:MINERAL CITY
Mailing Address - State:OH
Mailing Address - Zip Code:44656-0482
Mailing Address - Country:US
Mailing Address - Phone:330-324-2840
Mailing Address - Fax:
Practice Address - Street 1:2800 TUSKY VALLEY RD NE
Practice Address - Street 2:
Practice Address - City:MINERAL CITY
Practice Address - State:OH
Practice Address - Zip Code:44656-9691
Practice Address - Country:US
Practice Address - Phone:330-324-2840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400989351009374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241295Medicaid