MEDICARE: DEANNA JACKSON RN

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	163W00000X	Registered Nurse	402205	OH

General Provider Information

NPI Number	:	1053731703
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA JACKSON RN

Provider Business Mailing Address
First Line	:	3025 HAMPSHIRE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1661
Country	:	US
Telephone Number	:	216-682-5431
Fax Number	:

Provider Business Practice Location Address
First Line	:	3025 HAMPSHIRE RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-1661
Country	:	US
Telephone Number	:	216-682-5431
Fax Number	:

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

Provider Enumeration Date	:	04/21/2014
Last Update Date	:	12/11/2014

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