Provider Demographics
NPI:1689978470
Name:JACKSON, INDIA RACHELLE
Entity Type:Individual
Prefix:MISS
First Name:INDIA
Middle Name:RACHELLE
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 1:829 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-5636
Mailing Address - Country:US
Mailing Address - Phone:513-422-0676
Mailing Address - Fax:
Practice Address - Street 1:829 17TH AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-5636
Practice Address - Country:US
Practice Address - Phone:513-422-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400465690305376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide