Provider Demographics
NPI:1710666938
Name:JACKSON, DONOVAN
Entity type:Individual
Prefix:
First Name:DONOVAN
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 1:765 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1676
Mailing Address - Country:US
Mailing Address - Phone:330-861-8110
Mailing Address - Fax:
Practice Address - Street 1:765 WEST ST
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-1676
Practice Address - Country:US
Practice Address - Phone:234-799-0653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician