Provider Demographics
NPI:1861098659
Name:JACKSON, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
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 1:6700 AYLESHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-3866
Mailing Address - Country:US
Mailing Address - Phone:440-759-2512
Mailing Address - Fax:
Practice Address - Street 1:6700 AYLESHIRE DR
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-3866
Practice Address - Country:US
Practice Address - Phone:440-759-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH910001002810Medicaid