Provider Demographics
NPI:1447697800
Name:JACKSON, DEVONNA C
Entity type:Individual
Prefix:
First Name:DEVONNA
Middle Name:C
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 1:2330 E THIRD ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-5804
Mailing Address - Country:US
Mailing Address - Phone:937-580-4488
Mailing Address - Fax:
Practice Address - Street 1:2330 E THIRD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-5804
Practice Address - Country:US
Practice Address - Phone:937-301-4539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide