Provider Demographics
NPI:1336826213
Name:JACKSON, NECHELLE
Entity Type:Individual
Prefix:
First Name:NECHELLE
Middle Name:
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 1:4445 CORPORATION LN STE 264
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3671
Mailing Address - Country:US
Mailing Address - Phone:757-204-2691
Mailing Address - Fax:
Practice Address - Street 1:1312 JENNIE SCHER RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-1010
Practice Address - Country:US
Practice Address - Phone:804-591-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
VA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty