Provider Demographics
NPI:1982366845
Name:JACKSON, DAMITA (CNA)
Entity Type:Individual
Prefix:
First Name:DAMITA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 NE 81ST ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-8245
Mailing Address - Country:US
Mailing Address - Phone:816-783-7938
Mailing Address - Fax:
Practice Address - Street 1:1616 NE 81ST ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-8245
Practice Address - Country:US
Practice Address - Phone:816-783-7938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA189164246ZS0410X
MO100018A376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist