MEDICARE: DEVONNA C. 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

General Provider Information

NPI Number	:	1447697800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVONNA C. JACKSON

Provider Business Mailing Address
First Line	:	2330 E THIRD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-5804
Country	:	US
Telephone Number	:	937-580-4488
Fax Number	:

Provider Business Practice Location Address
First Line	:	2330 E THIRD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45402-5804
Country	:	US
Telephone Number	:	937-301-4539
Fax Number	:

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

Provider Enumeration Date	:	05/25/2013
Last Update Date	:	12/12/2016

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