Provider Demographics
NPI:1396334660
Name:JACKSON, JUDY L
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:L
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 1:40326 STATE ROUTE 681
Mailing Address - Street 2:
Mailing Address - City:SHADE
Mailing Address - State:OH
Mailing Address - Zip Code:45776-9518
Mailing Address - Country:US
Mailing Address - Phone:740-992-1797
Mailing Address - Fax:
Practice Address - Street 1:40326 STATE ROUTE 681
Practice Address - Street 2:
Practice Address - City:SHADE
Practice Address - State:OH
Practice Address - Zip Code:45776-9518
Practice Address - Country:US
Practice Address - Phone:740-992-1797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker