Provider Demographics
NPI:1891381745
Name:JACKSON, TAYLOR ANNE
Entity Type:Individual
Prefix:MISS
First Name:TAYLOR
Middle Name:ANNE
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 1:11311 HESSLER RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-3972
Mailing Address - Country:US
Mailing Address - Phone:724-996-2290
Mailing Address - Fax:
Practice Address - Street 1:18617 ALEXANDER RD
Practice Address - Street 2:
Practice Address - City:WALTON HILLS
Practice Address - State:OH
Practice Address - Zip Code:44146-5322
Practice Address - Country:US
Practice Address - Phone:724-996-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000272281Medicaid