Provider Demographics
NPI:1063117075
Name:JACKSON, GENNELL
Entity type:Individual
Prefix:
First Name:GENNELL
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 1:3422 BASSETT RD APT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2203
Mailing Address - Country:US
Mailing Address - Phone:513-543-5117
Mailing Address - Fax:
Practice Address - Street 1:3422 BASSETT RD APT 1
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45205-2203
Practice Address - Country:US
Practice Address - Phone:513-543-5117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion