Healthcare Provider Details

I. General information

NPI: 1326551607
Provider Name (Legal Business Name): RACHEL NICOLE JACKSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 CENTER ST
WHEELERSBURG OH
45694-1712
US

IV. Provider business mailing address

PO BOX 108
IRONTON OH
45638-0108
US

V. Phone/Fax

Practice location:
  • Phone: 740-776-2785
  • Fax: 740-776-2793
Mailing address:
  • Phone: 740-532-1613
  • Fax: 740-532-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.175596.MEDS-IV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: