Provider Demographics
NPI:1366229122
Name:JACKSON, NAOMI
Entity type:Individual
Prefix:
First Name:NAOMI
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 1:7691 62ND ST S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4676
Mailing Address - Country:US
Mailing Address - Phone:651-447-0398
Mailing Address - Fax:
Practice Address - Street 1:7691 62ND ST S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4676
Practice Address - Country:US
Practice Address - Phone:651-447-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1114922253J00000X
MN1112024253Z00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care