Provider Demographics
NPI:1720861784
Name:JACKSON III, ROBERT NATHANIEL
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NATHANIEL
Last Name:JACKSON III
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 1:65 PAW PAW DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 PAW PAW DR
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-1130
Practice Address - Country:US
Practice Address - Phone:937-367-2916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant