Provider Demographics
NPI:1811735756
Name:JACKSON, DESHAWNTE
Entity type:Individual
Prefix:
First Name:DESHAWNTE
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 1:12617 MAPLE LEAF DR
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-4026
Mailing Address - Country:US
Mailing Address - Phone:502-249-4758
Mailing Address - Fax:
Practice Address - Street 1:12617 MAPLE LEAF DR
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-4026
Practice Address - Country:US
Practice Address - Phone:502-249-4758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385H00000XRespite Care FacilityRespite Care