Provider Demographics
NPI:1881021384
Name:JACKSON, TASHAE L
Entity Type:Individual
Prefix:MS
First Name:TASHAE
Middle Name:L
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 1:1900 NEWTON ST APT H
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305-3069
Mailing Address - Country:US
Mailing Address - Phone:330-962-5918
Mailing Address - Fax:
Practice Address - Street 1:1900 NEWTON ST APT H
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305-3069
Practice Address - Country:US
Practice Address - Phone:330-962-5918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-141-207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHTLJ5918Medicaid
OHTLJ5918Medicare PIN
OHTLJ1122Medicare PIN
OHTLJ5918Medicaid
OHTLJ5918Medicare Oscar/Certification