Provider Demographics
NPI:1740845882
Name:JACKSON, DESHONE LAVETTE
Entity type:Individual
Prefix:
First Name:DESHONE
Middle Name:LAVETTE
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 1:2323 SHELVA LN
Mailing Address - Street 2:
Mailing Address - City:COPLEY
Mailing Address - State:OH
Mailing Address - Zip Code:44321-2534
Mailing Address - Country:US
Mailing Address - Phone:330-289-2364
Mailing Address - Fax:330-745-4629
Practice Address - Street 1:2323 SHELVA LN
Practice Address - Street 2:
Practice Address - City:COPLEY
Practice Address - State:OH
Practice Address - Zip Code:44321-2534
Practice Address - Country:US
Practice Address - Phone:330-289-2364
Practice Address - Fax:330-745-4629
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-03
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
OH02160123747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0216012Medicaid