Provider Demographics
NPI:1275420531
Name:JACKSON, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6984 DEERSVILLE AVENUE EXT SE
Mailing Address - Street 2:
Mailing Address - City:UHRICHSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44683-6342
Mailing Address - Country:US
Mailing Address - Phone:330-407-0488
Mailing Address - Fax:
Practice Address - Street 1:324 1ST DR NE
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-2718
Practice Address - Country:US
Practice Address - Phone:330-407-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHVK148608374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide