Provider Demographics
NPI:1104542208
Name:JACKSON, CHERYL RENEE
Entity type:Individual
Prefix:
First Name:CHERYL
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 1:12713 W DESERT ROSE RD
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-7007
Mailing Address - Country:US
Mailing Address - Phone:216-789-9116
Mailing Address - Fax:
Practice Address - Street 1:12713 W DESERT ROSE RD
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-7007
Practice Address - Country:US
Practice Address - Phone:216-789-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant