Provider Demographics
NPI:1881001220
Name:JACKSON, GWENETTE
Entity Type:Individual
Prefix:
First Name:GWENETTE
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 1:975 SNYDER ST
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-1859
Mailing Address - Country:US
Mailing Address - Phone:330-571-5233
Mailing Address - Fax:
Practice Address - Street 1:1340 WEATHERVANE LN APT 2B
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44313-5135
Practice Address - Country:US
Practice Address - Phone:330-689-6971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OH401529380613374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No374U00000XNursing Service Related ProvidersHome Health Aide