MEDICARE: DIAMOND JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide

General Provider Information

NPI Number	:	1053014597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIAMOND JACKSON

Provider Business Mailing Address
First Line	:	1777 MARKS AVE
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44305-4363
Country	:	US
Telephone Number	:	234-238-1438
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 MARKS AVE
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44305-4363
Country	:	US
Telephone Number	:	234-238-1438
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2023
Last Update Date	:	03/23/2023

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Directions to “ DIAMOND JACKSON ” Practice Location

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