Provider Demographics
NPI:1366277543
Name:JACKSON, JACQUELINE FAYE
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:FAYE
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 1:1645 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-3966
Mailing Address - Country:US
Mailing Address - Phone:567-249-3434
Mailing Address - Fax:
Practice Address - Street 1:1118 COUNTRY CREEK LN
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7029
Practice Address - Country:US
Practice Address - Phone:567-249-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4808846376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker