Provider Demographics
NPI:1518080811
Name:JACKSON, DERRICK O'NEAL (DPM)
Entity type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:O'NEAL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 E LIVINGSTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-1967
Mailing Address - Country:US
Mailing Address - Phone:866-953-3519
Mailing Address - Fax:614-239-1080
Practice Address - Street 1:420 OAK HILL AVENUE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44502-1415
Practice Address - Country:US
Practice Address - Phone:330-870-3900
Practice Address - Fax:330-870-3901
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30003456213E00000X
OH36003456213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology