Provider Demographics
NPI:1104063528
Name:JACOBSON GERLOSKY, NISSA NICOLE
Entity type:Individual
Prefix:MRS
First Name:NISSA
Middle Name:NICOLE
Last Name:JACOBSON GERLOSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NISSA
Other - Middle Name:NICOLE
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6355 NEWSTONE DR
Mailing Address - Street 2:#103
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-9231
Mailing Address - Country:US
Mailing Address - Phone:901-383-4462
Mailing Address - Fax:
Practice Address - Street 1:6355 NEWSTONE DR
Practice Address - Street 2:#103
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38135-9231
Practice Address - Country:US
Practice Address - Phone:901-383-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2762818Medicaid