Provider Demographics
NPI:1083843437
Name:JACKSON, MISTY A (LPN)
Entity type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 KITRIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424
Mailing Address - Country:US
Mailing Address - Phone:937-867-1793
Mailing Address - Fax:
Practice Address - Street 1:4301 KITRIDGE RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-6022
Practice Address - Country:US
Practice Address - Phone:937-867-1793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-133445-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse