Provider Demographics
NPI:1699182279
Name:JACKSON, DEJA
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:
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 1:2529 REEVES AVE
Mailing Address - Street 2:F6
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-4279
Mailing Address - Country:US
Mailing Address - Phone:440-654-9561
Mailing Address - Fax:
Practice Address - Street 1:2529 REEVES AVE
Practice Address - Street 2:F6
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4279
Practice Address - Country:US
Practice Address - Phone:440-654-9561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH41118080710376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide