Provider Demographics
NPI:1477436848
Name:JACKSON, LARUTH RENEE
Entity type:Individual
Prefix:
First Name:LARUTH
Middle Name:RENEE
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 1:6907 LUELDA AVE
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-1412
Mailing Address - Country:US
Mailing Address - Phone:212-162-5485
Mailing Address - Fax:
Practice Address - Street 1:6907 LUELDA AVE
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-1412
Practice Address - Country:US
Practice Address - Phone:212-162-5485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker