Provider Demographics
NPI:1831974112
Name:JACKSON, CHRISTIAN JOSELF
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:JOSELF
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 1:421 SOUTHERN BLVD NW APT 101
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44485-2543
Mailing Address - Country:US
Mailing Address - Phone:330-999-7745
Mailing Address - Fax:
Practice Address - Street 1:421 SOUTHERN BLVD NW APT 101
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2543
Practice Address - Country:US
Practice Address - Phone:330-999-7745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide