=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134518392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA LYNN JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10965 WEST STATE ROUTE 29
-----------------------------------------------------
City | ROSEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-926-6420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 45
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43078-0045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-926-6420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 0112400
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 376J00000X
-----------------------------------------------------
Taxonomy Name | Homemaker
-----------------------------------------------------
License Number | 0112400
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 401084350510
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | 0112400
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------