Provider Demographics
NPI:1386319622
Name:JACKSON, VERA LORRAINE
Entity type:Individual
Prefix:
First Name:VERA
Middle Name:LORRAINE
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 1:3905 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206
Mailing Address - Country:US
Mailing Address - Phone:443-325-6600
Mailing Address - Fax:
Practice Address - Street 1:3905 WHITE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206
Practice Address - Country:US
Practice Address - Phone:443-325-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home