Provider Demographics
NPI:1962034611
Name:JACKSON, RUTHETTE MARY (CROP AND FIRST AIDE)
Entity type:Individual
Prefix:
First Name:RUTHETTE
Middle Name:MARY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CROP AND FIRST AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 IRVING ST NW APT 201
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2435
Mailing Address - Country:US
Mailing Address - Phone:202-276-0378
Mailing Address - Fax:
Practice Address - Street 1:3002 RODMAN ST NW APT 306
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-3152
Practice Address - Country:US
Practice Address - Phone:202-297-4674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant