Provider Demographics
NPI:1629503693
Name:JACKSON, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
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 1:47 SUNNY LN
Mailing Address - Street 2:B
Mailing Address - City:SOUTH LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45065-1431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 SUNNY LN
Practice Address - Street 2:B
Practice Address - City:SOUTH LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45065-1431
Practice Address - Country:US
Practice Address - Phone:513-301-6266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker