Provider Demographics
NPI:1659815637
Name:JACKSON, CHANEL (STNA)
Entity Type:Individual
Prefix:
First Name:CHANEL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 W GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3273
Mailing Address - Country:US
Mailing Address - Phone:216-855-2969
Mailing Address - Fax:
Practice Address - Street 1:93 W GLENDALE ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-3273
Practice Address - Country:US
Practice Address - Phone:216-855-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-11
Last Update Date:2016-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400702651207374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide