Provider Demographics
NPI:1710409552
Name:JACKSON, CHANEL R
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:R
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 1:1471 HOWARD RD SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-4493
Mailing Address - Country:US
Mailing Address - Phone:202-607-3628
Mailing Address - Fax:
Practice Address - Street 1:1471 HOWARD RD SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-4493
Practice Address - Country:US
Practice Address - Phone:202-607-3628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant