Provider Demographics
NPI:1912357682
Name:JACKSON, IKISHIA N (RN)
Entity Type:Individual
Prefix:MS
First Name:IKISHIA
Middle Name:N
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:625 E GIRARD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3400
Mailing Address - Country:US
Mailing Address - Phone:267-439-0966
Mailing Address - Fax:215-425-4414
Practice Address - Street 1:625 E GIRARD AVE APT 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3400
Practice Address - Country:US
Practice Address - Phone:267-439-0966
Practice Address - Fax:215-425-4414
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA06650501163W00000X, 163WH0200X, 251B00000X, 251E00000X, 282J00000X, 343900000X, 374U00000X, 376J00000X, 385H00000X, 385H00000X, 282J00000X
PA652238251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No251B00000XAgenciesCase Management
No282J00000XHospitalsReligious Nonmedical Health Care Institution
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103310350-001Medicaid