Provider Demographics
NPI:1871291047
Name:JACKSON, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:126 BELLFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-4014
Mailing Address - Country:US
Mailing Address - Phone:216-551-4152
Mailing Address - Fax:
Practice Address - Street 1:126 BELLFIELD AVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-4014
Practice Address - Country:US
Practice Address - Phone:216-551-4152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant