Provider Demographics
NPI:1518659325
Name:JACKSON, KIMBERLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
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 252
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:OH
Mailing Address - Zip Code:45647-0252
Mailing Address - Country:US
Mailing Address - Phone:740-418-2533
Mailing Address - Fax:
Practice Address - Street 1:460 COTTERMAN LN
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:OH
Practice Address - Zip Code:45647-9778
Practice Address - Country:US
Practice Address - Phone:740-418-2533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide