Provider Demographics
NPI:1821229378
Name:JACKSON, KETURA L (RN)
Entity Type:Individual
Prefix:MRS
First Name:KETURA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13512 THORNHURST AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6851
Mailing Address - Country:US
Mailing Address - Phone:216-855-7775
Mailing Address - Fax:
Practice Address - Street 1:13512 THORNHURST AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44105-6851
Practice Address - Country:US
Practice Address - Phone:216-402-9617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2016003408363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily