Healthcare Provider Details

I. General information

NPI: 1295329381
Provider Name (Legal Business Name): MALAYSIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 E KEMPER RD STE 201
CINCINNATI OH
45246-3322
US

IV. Provider business mailing address

7975 CANADA AVE UNIT 712
ORLANDO FL
32819-9346
US

V. Phone/Fax

Practice location:
  • Phone: 513-400-4005
  • Fax:
Mailing address:
  • Phone: 513-400-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: