Provider Demographics
NPI:1356763593
Name:JACKSON, ANTONIA
Entity type:Individual
Prefix:
First Name:ANTONIA
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 1:1 N BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-1209
Mailing Address - Country:US
Mailing Address - Phone:139-814-2035
Mailing Address - Fax:
Practice Address - Street 1:1 N BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-1209
Practice Address - Country:US
Practice Address - Phone:139-814-2035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2025-04-29
Deactivation Date:2019-10-09
Deactivation Code:
Reactivation Date:2022-01-13
Provider Licenses
StateLicense IDTaxonomies
OH398426163W00000X
OHAPRN.CNP.0030393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse