Provider Demographics
NPI:1306059548
Name:JACKSON, PATRICIA L (HHA)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11379 E PIKE RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9162
Mailing Address - Country:US
Mailing Address - Phone:740-435-0343
Mailing Address - Fax:
Practice Address - Street 1:11379 E PIKE RD
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9162
Practice Address - Country:US
Practice Address - Phone:740-435-0343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2708583Medicaid