Provider Demographics
NPI:1679227847
Name:JACKSON, JAMIE AZURE LILLIAN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:AZURE LILLIAN
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 1:3230 E ROOSEVELT ST APT 221
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5119
Mailing Address - Country:US
Mailing Address - Phone:602-638-7974
Mailing Address - Fax:
Practice Address - Street 1:3230 E ROOSEVELT ST APT 221
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-5119
Practice Address - Country:US
Practice Address - Phone:602-638-7974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251S00000XAgenciesCommunity/Behavioral Health
No372600000XNursing Service Related ProvidersAdult Companion