Healthcare Provider Details

I. General information

NPI: 1982366845
Provider Name (Legal Business Name): DAMITA JACKSON CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 NE 81ST ST
KANSAS CITY MO
64118-8245
US

IV. Provider business mailing address

1616 NE 81ST ST
KANSAS CITY MO
64118-8245
US

V. Phone/Fax

Practice location:
  • Phone: 816-783-7938
  • Fax:
Mailing address:
  • Phone: 816-783-7938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number189164
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number100018A
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: