MEDICARE: MALAYSIA 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	246RP1900X	Phlebotomy Technician

General Provider Information

NPI Number	:	1295329381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALAYSIA JACKSON

Provider Business Mailing Address
First Line	:	7975 CANADA AVE UNIT 712
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-9346
Country	:	US
Telephone Number	:	513-400-4005
Fax Number	:

Provider Business Practice Location Address
First Line	:	1171 E KEMPER RD STE 201
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-3322
Country	:	US
Telephone Number	:	513-400-4005
Fax Number	:

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

Provider Enumeration Date	:	03/01/2021
Last Update Date	:	06/23/2021

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Directions to “ MALAYSIA JACKSON ” Practice Location

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