Provider Demographics
NPI:1386136497
Name:JACKSON, KIMIKA M
Entity type:Individual
Prefix:
First Name:KIMIKA
Middle Name:M
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 1:1661 ALPINE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43229-2162
Mailing Address - Country:US
Mailing Address - Phone:614-778-0815
Mailing Address - Fax:
Practice Address - Street 1:1661 ALPINE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-2162
Practice Address - Country:US
Practice Address - Phone:614-778-0815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD1600X, 376J00000X, 252Y00000X, 251E00000X, 320900000X, 253Z00000X, 385H00000X, 374U00000X, 343900000X, 261QA0600X, 385HR2060X
OHFPS.000303175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No376J00000XNursing Service Related ProvidersHomemaker
No252Y00000XAgenciesEarly Intervention Provider Agency
No251E00000XAgenciesHome Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No175T00000XOther Service ProvidersPeer Specialist
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child