MEDICARE: DONCHELLE JACKSON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	376J00000X	Homemaker
2	385H00000X	Respite Care
3	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1942961313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONCHELLE JACKSON

Provider Business Mailing Address
First Line	:	6547 N BOUVIER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19126-3414
Country	:	US
Telephone Number	:	267-904-1958
Fax Number	:

Provider Business Practice Location Address
First Line	:	6547 N BOUVIER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19126-3414
Country	:	US
Telephone Number	:	267-904-1958
Fax Number	:

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

Provider Enumeration Date	:	01/06/2022
Last Update Date	:	01/06/2022

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Directions to “ DONCHELLE JACKSON ” Practice Location

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