MEDICARE: CRYSTAL LA'NAE 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	374J00000X	Doula	DOU.000128	OH

General Provider Information

NPI Number	:	1245026384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL LA'NAE JACKSON

Provider Business Mailing Address
First Line	:	6511 MARSOL RD APT 214
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3544
Country	:	US
Telephone Number	:	216-358-4935
Fax Number	:

Provider Business Practice Location Address
First Line	:	6511 MARSOL RD APT 214
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3544
Country	:	US
Telephone Number	:	216-358-4935
Fax Number	:

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

Provider Enumeration Date	:	04/16/2025
Last Update Date	:	04/16/2025

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