MEDICARE: MISS JUDITH LYNN 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	3747A0650X	Attendant Care Provider

General Provider Information

NPI Number	:	1114575016
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JUDITH LYNN JACKSON

Provider Business Mailing Address
First Line	:	2820 N CHERRY ST APT C105
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-5009
Country	:	US
Telephone Number	:	509-413-2792
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 N CHERRY ST APT C105
Second Line	:
City	:	SPOKANE VALLEY
State	:	WA
Zip	:	99216-5009
Country	:	US
Telephone Number	:	509-413-2792
Fax Number	:

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

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	09/04/2019

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