Healthcare Provider Details

I. General information

NPI: 1174446413
Provider Name (Legal Business Name): TINA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5810 JASSAMINE DR
DAYTON OH
45449-2943
US

IV. Provider business mailing address

5810 JASSAMINE DR
DAYTON OH
45449-2943
US

V. Phone/Fax

Practice location:
  • Phone: 937-430-4369
  • Fax:
Mailing address:
  • Phone: 937-430-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number5718476
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: