Provider Demographics
NPI:1134965486
Name:JACKSON, TASIA KIARA
Entity type:Individual
Prefix:
First Name:TASIA
Middle Name:KIARA
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 1:4464 PARKTON DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-3532
Mailing Address - Country:US
Mailing Address - Phone:216-659-1714
Mailing Address - Fax:
Practice Address - Street 1:4464 PARKTON DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-3532
Practice Address - Country:US
Practice Address - Phone:216-659-1714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-06
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH602669220623376K00000X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant