Provider Demographics
NPI:1881174365
Name:JACKSON, KEISHA
Entity type:Individual
Prefix:MS
First Name:KEISHA
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 1:3578-A HAYES ST. N.E. APT# 302
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019
Mailing Address - Country:US
Mailing Address - Phone:202-878-4051
Mailing Address - Fax:
Practice Address - Street 1:3718 HAYES ST. N.E. APT# 201
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019
Practice Address - Country:US
Practice Address - Phone:202-399-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant