Provider Demographics
NPI:1770121378
Name:JACKSON, ALEXIS ADRIANNA
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:ADRIANNA
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 1:1205 PARKMAN RD NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2470
Mailing Address - Country:US
Mailing Address - Phone:330-942-1456
Mailing Address - Fax:
Practice Address - Street 1:1205 PARKMAN RD NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2470
Practice Address - Country:US
Practice Address - Phone:330-942-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0374711Medicaid