Healthcare Provider Details

I. General information

NPI: 1467369082
Provider Name (Legal Business Name): ADEOLA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2459 DITTANY LN
LEXINGTON KY
40511-9281
US

IV. Provider business mailing address

2459 DITTANY LN APT A22
LEXINGTON KY
40511-9281
US

V. Phone/Fax

Practice location:
  • Phone: 859-202-2565
  • Fax:
Mailing address:
  • Phone: 859-202-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: