Provider Demographics
NPI:1720978638
Name:JACKSON, LETITIA MACHELLE
Entity type:Individual
Prefix:
First Name:LETITIA
Middle Name:MACHELLE
Last Name:JACKSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 PHIIPPI RD
Mailing Address - Street 2:
Mailing Address - City:VOLGA
Mailing Address - State:WV
Mailing Address - Zip Code:26238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:955 PHIIPPI RD
Practice Address - Street 2:
Practice Address - City:VOLGA
Practice Address - State:WV
Practice Address - Zip Code:26238
Practice Address - Country:US
Practice Address - Phone:304-906-5381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide