Provider Demographics
NPI:1205430881
Name:JACKSON, SENTELL
Entity type:Individual
Prefix:
First Name:SENTELL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 GLENMORE AVE STE 11B
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2258
Mailing Address - Country:US
Mailing Address - Phone:334-224-2677
Mailing Address - Fax:
Practice Address - Street 1:3012 GLENMORE AVE STE 11B
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2258
Practice Address - Country:US
Practice Address - Phone:334-224-2677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health