Provider Demographics
NPI:1689443608
Name:JACKSON, TERRICINA LAVETTE
Entity Type:Individual
Prefix:
First Name:TERRICINA
Middle Name:LAVETTE
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 1:2513 ADAMS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3123
Mailing Address - Country:US
Mailing Address - Phone:989-213-9419
Mailing Address - Fax:
Practice Address - Street 1:2513 ADAMS BLVD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3123
Practice Address - Country:US
Practice Address - Phone:989-213-9419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Single Specialty