Provider Demographics
NPI:1770963514
Name:JACKSON, FURAE
Entity type:Individual
Prefix:
First Name:FURAE
Middle Name:
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 1:19550 EUCLID AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1432
Mailing Address - Country:US
Mailing Address - Phone:216-583-6018
Mailing Address - Fax:
Practice Address - Street 1:19550 EUCLID AVE APT 303
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44117-1432
Practice Address - Country:US
Practice Address - Phone:216-583-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-07
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172V00000XOther Service ProvidersCommunity Health Worker