Provider Demographics
NPI:1811952765
Name:JACKSON, JACQUELINE DIANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 KENYON AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-6413
Mailing Address - Country:US
Mailing Address - Phone:440-322-7644
Mailing Address - Fax:
Practice Address - Street 1:417 KENYON AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6413
Practice Address - Country:US
Practice Address - Phone:440-322-7644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN084359164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse