Provider Demographics
NPI:1023719812
Name:JACKSON, ASHANTI (LPN)
Entity type:Individual
Prefix:MRS
First Name:ASHANTI
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11200 TARA GLYNN DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-2686
Mailing Address - Country:US
Mailing Address - Phone:314-736-0679
Mailing Address - Fax:
Practice Address - Street 1:11200 TARA GLYNN DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-2686
Practice Address - Country:US
Practice Address - Phone:314-386-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018040059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse