MEDICARE: JOELISA W 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	146N00000X	Basic Emergency Medical Technician	1256-0428-1822	DC
2	3747P1801X	Personal Care Attendant		DC

General Provider Information

NPI Number	:	1679261218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOELISA W JACKSON

Provider Business Mailing Address
First Line	:	5118 JUST ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20019-5560
Country	:	US
Telephone Number	:	202-802-1644
Fax Number	:

Provider Business Practice Location Address
First Line	:	5118 JUST ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20019-5560
Country	:	US
Telephone Number	:	202-802-1644
Fax Number	:

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

Provider Enumeration Date	:	05/01/2023
Last Update Date	:	05/01/2023

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