Provider Demographics
NPI:1992416580
Name:JACKSON, VICTORIA (CNA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66102-2960
Mailing Address - Country:US
Mailing Address - Phone:816-791-3174
Mailing Address - Fax:
Practice Address - Street 1:1126 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66102-2960
Practice Address - Country:US
Practice Address - Phone:816-791-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO89290A251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care