Provider Demographics
NPI:1720444839
Name:JACKSON, VERNEEKY CARENDA (PERSONAL CARE AIDE)
Entity Type:Individual
Prefix:MS
First Name:VERNEEKY
Middle Name:CARENDA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PERSONAL CARE AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 SPRENKLE LN APT C
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3580
Mailing Address - Country:US
Mailing Address - Phone:804-502-5897
Mailing Address - Fax:804-501-5274
Practice Address - Street 1:8260 ATLEE ROAD
Practice Address - Street 2:BON SECOURS MEMORIAL REGIONAL MEDICAL CENTER
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2309
Practice Address - Country:US
Practice Address - Phone:804-764-6000
Practice Address - Fax:804-764-6324
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG65102Medicare UPIN
MIG68868Medicare UPIN
FLAE491ZMedicare PIN
VA497026CMedicare Oscar/Certification
VA390000110Medicare PIN
VAG28365Medicare UPIN
VAG85907Medicare UPIN
VA0962280006Medicare NSC
VA490069Medicare Oscar/Certification
VA0472640012Medicare NSC
VA0472640003Medicare NSC