Healthcare Provider Details

I. General information

NPI: 1669910980
Provider Name (Legal Business Name): JACQUELINE F JACKSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4207 SECOR RD APT 242
TOLEDO OH
43623-4221
US

IV. Provider business mailing address

4207 SECOR ROAD APT 242
TOLEDO OH
43623
US

V. Phone/Fax

Practice location:
  • Phone: 419-270-2592
  • Fax:
Mailing address:
  • Phone: 419-270-2592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberSK455996
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberSK455996
License Number StateOH

VIII. Authorized Official

Name: MS. JACQUELINE JACKSON JACKSON
Title or Position: OWNER
Credential:
Phone: 419-270-2592