Provider Demographics
NPI:1780341172
Name:JACKSON, DEMETRIUS WILLIAM
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:WILLIAM
Last Name:JACKSON
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 1:2320 24TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3402
Mailing Address - Country:US
Mailing Address - Phone:202-491-4420
Mailing Address - Fax:
Practice Address - Street 1:3921 S ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-1062
Practice Address - Country:US
Practice Address - Phone:202-468-5522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-21
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant