Provider Demographics
NPI:1205624327
Name:JACKSON, JENNAH-LI EULALIA
Entity type:Individual
Prefix:
First Name:JENNAH-LI
Middle Name:EULALIA
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 LO BELL DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-1371
Mailing Address - Country:US
Mailing Address - Phone:412-485-1426
Mailing Address - Fax:
Practice Address - Street 1:6 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:SNOW HILL
Practice Address - State:NC
Practice Address - Zip Code:28580-1333
Practice Address - Country:US
Practice Address - Phone:252-747-8162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program