MEDICARE: BILLY JEROME 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		OH
2	376J00000X	Homemaker		OH
3	172A00000X	Driver	RQ788849	OH

General Provider Information

NPI Number	:	1487242400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BILLY JEROME JACKSON

Provider Business Mailing Address
First Line	:	3225 AMANDA DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-1102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 AMANDA DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-1102
Country	:	US
Telephone Number	:	937-789-6646
Fax Number	:

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

Provider Enumeration Date	:	01/05/2021
Last Update Date	:	01/05/2021

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