Healthcare Provider Details

I. General information

NPI: 1356763593
Provider Name (Legal Business Name): ANTONIA JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date: 10/09/2019
Reactivation Date: 01/13/2022

III. Provider practice location address

1 N BROOKWOOD AVE
HAMILTON OH
45013-1209
US

IV. Provider business mailing address

1 N BROOKWOOD AVE
HAMILTON OH
45013-1209
US

V. Phone/Fax

Practice location:
  • Phone: 139-814-2035
  • Fax:
Mailing address:
  • Phone: 139-814-2035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030393
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number398426
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: