MEDICARE: THIA R 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1962251595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THIA R JACKSON

Provider Business Mailing Address
First Line	:	1016 BUNCHE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-4418
Country	:	US
Telephone Number	:	937-657-1719
Fax Number	:

Provider Business Practice Location Address
First Line	:	1016 BUNCHE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45417-4418
Country	:	US
Telephone Number	:	937-657-1719
Fax Number	:

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

Provider Enumeration Date	:	05/15/2024
Last Update Date	:	05/15/2024

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