Provider Demographics
NPI:1649865858
Name:JACKSON, MYRNA DESIREE
Entity type:Individual
Prefix:MISS
First Name:MYRNA
Middle Name:DESIREE
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 1:6315 SUITLAND RD
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-3400
Mailing Address - Country:US
Mailing Address - Phone:240-305-7772
Mailing Address - Fax:
Practice Address - Street 1:1301 7TH ST NW APT 222
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-3515
Practice Address - Country:US
Practice Address - Phone:202-253-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant