Provider Demographics
NPI:1578348199
Name:JACKSON, DANIELLE N
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:N
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 1:3366 W 130TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-2614
Mailing Address - Country:US
Mailing Address - Phone:216-203-1668
Mailing Address - Fax:
Practice Address - Street 1:3366 W 130TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-2614
Practice Address - Country:US
Practice Address - Phone:216-203-1668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172A00000X, 251X00000X, 253Z00000X, 3747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant