MEDICARE: DENISE MARCEL 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	374U00000X	Home Health Aide		OH
2	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1245828540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE MARCEL JACKSON

Provider Business Mailing Address
First Line	:	3825 GROSVENOR RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-2313
Country	:	US
Telephone Number	:	216-246-4265
Fax Number	:

Provider Business Practice Location Address
First Line	:	3825 GROSVENOR RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44118-2313
Country	:	US
Telephone Number	:	216-246-4265
Fax Number	:

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

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/04/2021

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