MEDICARE: MRS. KATHY LORINE 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	3747P1801X	Personal Care Attendant	I502513	WV

General Provider Information

NPI Number	:	1255940391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHY LORINE JACKSON

Provider Business Mailing Address
First Line	:	2504 TOMS CREEK RD
Second Line	:
City	:	WAYNE
State	:	WV
Zip	:	25570-9458
Country	:	US
Telephone Number	:	304-272-3528
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 TOMS CREEK RD
Second Line	:
City	:	WAYNE
State	:	WV
Zip	:	25570-9458
Country	:	US
Telephone Number	:	304-272-3528
Fax Number	:

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

Provider Enumeration Date	:	07/24/2020
Last Update Date	:	07/24/2020

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