Provider Demographics
NPI:1376348433
Name:LYIMO, JACKSON W
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:W
Last Name:LYIMO
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 1:835 CORYLUS DR
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-7593
Mailing Address - Country:US
Mailing Address - Phone:316-204-0178
Mailing Address - Fax:
Practice Address - Street 1:835 CORYLUS DR
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-7593
Practice Address - Country:US
Practice Address - Phone:316-204-0178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant