Healthcare Provider Details

I. General information

NPI: 1154671816
Provider Name (Legal Business Name): JAMIE KAY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7409 PATRICK HENRY CT APT. 8
LOUISVILLE KY
40214-5239
US

IV. Provider business mailing address

7409 PATRICK HENRY CT APT. 8
LOUISVILLE KY
40214-5239
US

V. Phone/Fax

Practice location:
  • Phone: 502-876-4548
  • Fax:
Mailing address:
  • Phone: 502-876-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number50178368
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number50178368
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: