MEDICARE: ETHEL 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

General Provider Information

NPI Number	:	1992460331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHEL JACKSON

Provider Business Mailing Address
First Line	:	3212 ASPINWALL CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6531
Country	:	US
Telephone Number	:	856-345-7883
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 ASPINWALL CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6531
Country	:	US
Telephone Number	:	856-345-7883
Fax Number	:

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

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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