Provider Demographics
NPI:1518184878
Name:JACKSON, NINA LINDSAY
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:LINDSAY
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 1:1575 COMANCHE RD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-2556
Mailing Address - Country:US
Mailing Address - Phone:410-956-3559
Mailing Address - Fax:
Practice Address - Street 1:140 STEPNEY LN
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2801
Practice Address - Country:US
Practice Address - Phone:410-956-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02322225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist