Provider Demographics
NPI:1912133398
Name:JACKSON, JASMINE NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:NICOLE
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 1:1730 KENSINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-3912
Mailing Address - Country:US
Mailing Address - Phone:937-829-3470
Mailing Address - Fax:
Practice Address - Street 1:1730 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-3912
Practice Address - Country:US
Practice Address - Phone:937-829-3470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-30
Last Update Date:2009-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN115700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse