Provider Demographics
NPI:1891153219
Name:JACKSON, JARRELL T
Entity Type:Individual
Prefix:
First Name:JARRELL
Middle Name:T
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JARRELL
Other - Middle Name:T
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1528 PALMETTO ST
Mailing Address - Street 2:APT A
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1528
Mailing Address - Country:US
Mailing Address - Phone:757-741-7355
Mailing Address - Fax:
Practice Address - Street 1:1528 PALMETTO ST
Practice Address - Street 2:APT A
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1528
Practice Address - Country:US
Practice Address - Phone:757-741-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant