Provider Demographics
NPI:1790350098
Name:JACKSON, JESSICA JO
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JO
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 1:408 E IRON AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2108
Mailing Address - Country:US
Mailing Address - Phone:330-447-6091
Mailing Address - Fax:
Practice Address - Street 1:408 E IRON AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2108
Practice Address - Country:US
Practice Address - Phone:330-447-6091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0214919374U00000X
OH374U00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214919Medicaid