MEDICARE: ENDIA JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1417605940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENDIA JACKSON

Provider Business Mailing Address
First Line	:	5963 KENTSHIRE DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45440-4253
Country	:	US
Telephone Number	:	937-952-6379
Fax Number	:

Provider Business Practice Location Address
First Line	:	26055 EMERY RD STE G
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-6211
Country	:	US
Telephone Number	:	216-342-4445
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	02/28/2024

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Directions to “ ENDIA JACKSON ” Practice Location

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