Provider Demographics
NPI:1790002723
Name:JACKSON, LALISHA REANEE (MEDICAL ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:LALISHA
Middle Name:REANEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MEDICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4356 E 144TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2314
Mailing Address - Country:US
Mailing Address - Phone:216-323-8427
Mailing Address - Fax:
Practice Address - Street 1:4356 E 144TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2314
Practice Address - Country:US
Practice Address - Phone:216-323-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-30
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide