Healthcare Provider Details

I. General information

NPI: 1023477247
Provider Name (Legal Business Name): ANNA JACKSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date: 07/07/2020
Reactivation Date: 07/14/2020

III. Provider practice location address

630 HALLIE AVE
AKRON OH
44305-2606
US

IV. Provider business mailing address

630 HALLIE AVE
AKRON OH
44305-2606
US

V. Phone/Fax

Practice location:
  • Phone: 614-603-6440
  • Fax:
Mailing address:
  • Phone: 614-603-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number473110
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: