Provider Demographics
NPI:1689451502
Name:JACKSON, KISHA ELAINE (CASE MANAGER)
Entity type:Individual
Prefix:MS
First Name:KISHA
Middle Name:ELAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-1806
Mailing Address - Country:US
Mailing Address - Phone:440-258-1564
Mailing Address - Fax:
Practice Address - Street 1:1840 E 29TH ST
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-1806
Practice Address - Country:US
Practice Address - Phone:440-258-1564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No171M00000XOther Service ProvidersCase Manager/Care Coordinator