Provider Demographics
NPI:1700202587
Name:JACKSON, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
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 1:503 CANDACE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-3752
Mailing Address - Country:US
Mailing Address - Phone:937-206-2724
Mailing Address - Fax:
Practice Address - Street 1:503 CANDACE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-3752
Practice Address - Country:US
Practice Address - Phone:937-206-2724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH302032163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse