Provider Demographics
NPI:1720491434
Name:JACKSON, NAKIA (STNA)
Entity Type:Individual
Prefix:MISS
First Name:NAKIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 COURTRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4212
Mailing Address - Country:US
Mailing Address - Phone:216-235-6819
Mailing Address - Fax:
Practice Address - Street 1:2137 COURTRIGHT RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4212
Practice Address - Country:US
Practice Address - Phone:216-235-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400347510404374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3009667Medicaid