Healthcare Provider Details

I. General information

NPI: 1841618063
Provider Name (Legal Business Name): SKYLAR T. JACKSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 N MCCORD RD
TOLEDO OH
43615-4835
US

IV. Provider business mailing address

PO BOX 352501
TOLEDO OH
43635-2501
US

V. Phone/Fax

Practice location:
  • Phone: 419-450-9943
  • Fax:
Mailing address:
  • Phone: 419-450-9943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.399807
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: