Provider Demographics
NPI:1790253797
Name:JACKSON, TALIAH
Entity Type:Individual
Prefix:
First Name:TALIAH
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 1:3203 REED ST APT 2821
Mailing Address - Street 2:
Mailing Address - City:GLENARDEN
Mailing Address - State:MD
Mailing Address - Zip Code:20706-1546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1616 MARION ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3468
Practice Address - Country:US
Practice Address - Phone:301-523-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant