MEDICARE: RENEE 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

General Provider Information

NPI Number	:	1417455502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE JACKSON

Provider Business Mailing Address
First Line	:	3539 E CAPITOL ST SE APT 201
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20019-1212
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3539 E CAPITOL ST SE APT 201
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20019-1212
Country	:	US
Telephone Number	:	202-491-7528
Fax Number	:

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

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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Directions to “ RENEE JACKSON ” Practice Location

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