Healthcare Provider Details

I. General information

NPI: 1316782865
Provider Name (Legal Business Name): MS. LANEASZE C JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 E PARK ST APT 7
CARBONDALE IL
62901-4031
US

IV. Provider business mailing address

1061 E PARK ST APT 7
CARBONDALE IL
62901-4031
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-1592
  • Fax:
Mailing address:
  • Phone: 937-522-1592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: