Provider Demographics
NPI:1952174864
Name:JACKSON, RODNESIA RENEE
Entity type:Individual
Prefix:MISS
First Name:RODNESIA
Middle Name:RENEE
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 1:4212 HARBOR CRK
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-2843
Mailing Address - Country:US
Mailing Address - Phone:248-230-0005
Mailing Address - Fax:
Practice Address - Street 1:4212 HARBOR CRK
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-2843
Practice Address - Country:US
Practice Address - Phone:248-230-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula