Provider Demographics
NPI:1932758158
Name:JACKSON, RENETIA
Entity Type:Individual
Prefix:
First Name:RENETIA
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 1:1210 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024
Mailing Address - Country:US
Mailing Address - Phone:612-702-8541
Mailing Address - Fax:
Practice Address - Street 1:1210 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55024
Practice Address - Country:US
Practice Address - Phone:612-702-8541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider