Provider Demographics
NPI:1619283470
Name:JACKSON, DAVID JOHN (LPN)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 KITRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-6022
Mailing Address - Country:US
Mailing Address - Phone:937-681-6484
Mailing Address - Fax:
Practice Address - Street 1:4301 KITRIDGE RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-6022
Practice Address - Country:US
Practice Address - Phone:937-681-6484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140833164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse