Individual
CHARLENE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
2075 RIPLEY ST, LAKE STATION, IN 46405-1161
(219) 962-9437
Mailing address
1063 WALLACE ST, GARY, IN 46404-1818
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
27031267A
IN
Other
Enumeration date
06/02/2010
Last updated
06/02/2010
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