MEDICARE: WANDA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	HHA11761	DC

General Provider Information

NPI Number	:	1538525175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA JACKSON

Provider Business Mailing Address
First Line	:	1709 L ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-3021
Country	:	US
Telephone Number	:	301-613-5259
Fax Number	:

Provider Business Practice Location Address
First Line	:	1709 L ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20002-3021
Country	:	US
Telephone Number	:	301-613-5259
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2016
Last Update Date	:	01/12/2016

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Directions to “ WANDA JACKSON ” Practice Location

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