Provider Demographics
NPI:1255211447
Name:JACKSON, TEDRA
Entity type:Individual
Prefix:
First Name:TEDRA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:782 E 130TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108-2544
Mailing Address - Country:US
Mailing Address - Phone:216-334-3163
Mailing Address - Fax:
Practice Address - Street 1:782 E 130TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-2544
Practice Address - Country:US
Practice Address - Phone:216-334-3163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251C00000X, 251X00000X, 253Z00000X, 332U00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No332U00000XSuppliersHome Delivered Meals