Provider Demographics
NPI:1700552262
Name:JACKSON, CASSANDRA E
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:E
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:E
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2998 E 123RD ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2968
Mailing Address - Country:US
Mailing Address - Phone:216-294-9937
Mailing Address - Fax:
Practice Address - Street 1:2998 E 123RD ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2968
Practice Address - Country:US
Practice Address - Phone:216-294-9937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH579624Medicaid