Provider Demographics
NPI:1710573068
Name:JACKSON, LEE ANN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
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 1:57 1/2 PAXTON ST
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26750-1311
Mailing Address - Country:US
Mailing Address - Phone:394-790-3251
Mailing Address - Fax:
Practice Address - Street 1:57 1/2 PAXTON ST
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:WV
Practice Address - Zip Code:26750-1311
Practice Address - Country:US
Practice Address - Phone:394-790-3251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV185193747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant