Individual
LARESA A JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
924 IDA RD., CLEVELAND, OH 44103
(216) 210-1772
Mailing address
924 IDA RD., CLEVELAND, OH 44103
(216) 210-1772
Taxonomy
Speciality
Code
Description
License number
State
376K00000X
Nurse's Aide
Primary
400348660404
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
400348660404
STNA CERTIFICATION
OH
Enumeration date
09/05/2012
Last updated
09/05/2012
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