Provider Demographics
NPI:1295908051
Name:JACKSON, CHRISTY DANIELLE (NURSE)
Entity type:Individual
Prefix:MS
First Name:CHRISTY
Middle Name:DANIELLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 COURTLAND ST
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-3167
Mailing Address - Country:US
Mailing Address - Phone:440-324-5709
Mailing Address - Fax:
Practice Address - Street 1:409 COURTLAND ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-3167
Practice Address - Country:US
Practice Address - Phone:440-324-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN102812167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician