Provider Demographics
NPI:1639668015
Name:JACKSON, WADEEHA MAHASIN (MBA)
Entity Type:Individual
Prefix:
First Name:WADEEHA
Middle Name:MAHASIN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MADISON AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-7337
Mailing Address - Country:US
Mailing Address - Phone:973-285-3184
Mailing Address - Fax:
Practice Address - Street 1:55 MADISON AVE STE 4
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-7337
Practice Address - Country:US
Practice Address - Phone:973-285-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0275400374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide