Provider Demographics
NPI:1902244312
Name:JACKSON, JEREMY (DO, MPH)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 FINGER LKS
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3121
Mailing Address - Country:US
Mailing Address - Phone:740-505-3022
Mailing Address - Fax:
Practice Address - Street 1:405 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45405-4720
Practice Address - Country:US
Practice Address - Phone:937-723-3567
Practice Address - Fax:937-723-5017
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005405A207P00000X
390200000X
OH011603207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program